Key Points

  • Opioid administration results in increased intracranial pressure and in decreased mean arterial pressure, and thus is not beneficial in the management of acute ABI.
     
  • Administering an opioid prior to administering a hypnotic agent results in faster arousal, and thus may be desirable in the acute management of ABI.
     
  • Carbamazepine has no effect on cognitive performance.
     
  • Carbamazepine helps in the reduction of aggression following brain injury.
     
  • Intramuscular midazolam may be effective for acute seizure cessation.
     
  • Levetiracetam is as effective as phenytoin in treating and preventing seizures in individuals in the intensive care unit post ABI.
     
  • Anticonvulsants provided immediately post ABI reduce the occurrence of seizures only within the first week.
     
  • Anticonvulsants provided shortly post ABI do not reduce late seizures.
     
  • Anticonvulsants have negative consequences on motor tasks.
     
  • Phenobarbital has not been shown to be effective in reducing the risk of late seizure development post ABI.
     
  • Valproic acid and divalproex may be used to decrease the incidence of aggressive behaviour; however, more research is needed.
     
  • Lamotrigine may be successful in reducing pathologic laughing post TBI.
     
  • Cerebrolysin may be beneficial for the improvement of clinical outcome and cognitive functioning following brain injury; however, controlled trials are needed to further evaluate its efficacy.
     
  • Donepezil helps to improve attention, short-term, long-term, and visual memory following brain injury.
     
  • Physostigmine improves long-term memory in men with TBI.
     
  • The effectiveness of sertraline in treating depression post TBI is unclear.
     
  • Citalopram is helpful in the reduction of depression post ABI.
     
  • Citalopram and carbamazepine are effective in the treatment of mood disorders.
     
  • Desipramine is effective in reducing depression.
     
  • Sertraline HCl can be useful in reducing aggressive and irritable behaviours.
     
  • Amitriptyline can be used to decrease agitation.
     
  • Lithium may reduce behavioural problems but is associated with a high risk of neurotoxicity.
     
  • Although there is evidence to suggest that quetiapine does help reduce aggressive behaviour, more research is needed.
     
  • Ziprasidone in one small study has been shown to assist in the controlling of agitation; however more research is needed.
     
  • Haloperidol appears to have little negative effect on recovery following TBI.
     
  • Droperidol may be an effective agent for calming agitated patients.
     
  • Phenol blocks of the musculocutaneous nerve may help decrease spasticity and improve range of motion temporarily up to five months post injection.
     
  • Oral baclofen appears to reduce lower extremity spastic hypertonia.
     
  • Oral baclofen did not improve tone, spasm frequency of reflexes in the upper extremity.
     
  • Botulinum toxin type A injections reduce localized spasticity and improve range of motion following ABI.
     
  • Patients receiving botulinum toxin type A through a single motor point or through multisite distributed injections both show a reduction in spasticity.
     
  • Bolus injections of intrathecal baclofen produce short-term reductions in upper and lower extremity spasticity post ABI.
     
  • Prolonged intrathecal baclofen reduces upper and lower extremity spasticity post ABI.
     
  • Intrathecal baclofen may cause short-term improvements in walking performance in ambulatory patients post ABI.
     
  • Pentobarbital is not effective for intracranial pressure management.
     
  • Pentobarbital is not better than mannitol for the control of elevated intracranial pressure.
     
  • Barbiturate therapy may improve metabolic functions.
     
  • Patients undergoing barbiturate therapy should have their immunological response and systemic blood pressure monitored.
     
  • Barbiturate therapy plus hypothermia may improve clinical outcomes.
     
  • Etidronate prevents the development of heterotopic ossification.
     
  • There is conflicting evidence on the effectiveness of dexanabinol; however, based on a high quality RCT with a large sample size, is not effective in controlling intracranial pressure or in improving clinical outcomes post ABI.
     
  • KN38-7271 provides improvements in cerebral perfusion pressure control during the acute phase post ABI.
     
  • Pindolol can decrease aggressive behaviour following brain injury.
     
  • Propranolol reduces aggressive and agitated symptoms following brain injury.
     
  • Sodium lactate is more effective than mannitol for reducing acute elevations in intracranial pressure.
     
  • High dose mannitol results in lower mortality rates and better clinical outcomes compared with conventional mannitol.
     
  • Early out of hospital administration of mannitol does not negatively affect blood pressure.
     
  • Mannitol may only lower intracranial pressure (ICP) when initial ICP values are abnormally elevated.
     
  • Amantadine improves consciousness and cognitive function in comatose adult ABI patients.
     
  • Amantadine and pramipexole are effective in improving levels of consciousness in children post TBI.
     
  • Amantadine has been shown to be ineffective in improving attention and memory deficits. Its impact on executive functioning should be studied further.
     
  • Dopamine enhancing drugs may accelerate the rate of recovery from a low response state post TBI in children.
     
  • Bromocriptine improves some executive cognitive functions such as dual task performance and motivational deficits but it does not consistently improve memory. More research is needed before the benefits of using bromocriptine to enhance cognitive functioning are known.
     
  • Administration of dexamethasone inhibits endogenous production of glucocorticoids in children.
     
  • Dexamethasone administration has no proven impact on recovery post brain injury in children.
     
  • Medroxyprogesterone intramuscularly may reduce sexual aggression.
     
  • There is conflicting evidence regarding the effectiveness of progesterone on functional outcomes.
     
  • It remains unclear as to whether progesterone improves mortality in patients with ABI.
     
  • The effectiveness of methylphenidate treatment to improve cognitive impairment following brain injury is unclear.
     
  • Methylphenidate is effective in improving reaction time for working memory.
     
  • Response to methylphenidate may depend on genotype.
     
  • Methylphenidate does not have an adverse effect on the sleep-wake cycle of those who have sustained a TBI when given in commonly accepted dosages.
     
  • Evidence regarding the efficacy of methylphenidate to improve cognitive and behavioural function is conflicting in children.
     
  • Modafinil has not been shown to be effective in treating fatigue.
     
  • Modafinil has been shown to be effective short-term in treating excessive daytime sleepiness, but may also cause insomnia. 
     
  • Propofol helps to reduce intracranial pressure and the need for other sedative interventions when used in conjunction with morphine.
     
  • Midazolam has no effect on intracranial pressure but may result in systemic hypotension.
     
  • Methylprednisolone increases mortality rates in patients with ABI and should not be used.
     
  • Triamcinolone has been shown to improve outcomes in patients with both a Glasgow Coma Scale <8 and a focal lesion.
     
  • Dexamethasone does not improve intracranial pressure (ICP) levels and may worsen outcomes in patients with ICP >20mmHg.
     
  • Glucocorticoid administration increases the risk of developing first late seizures when administered within one day post injury; however, it does not impact late seizures when administered outside that time frame.