Abstract
After intervention in ruptured anterior communicant artery aneurysm (ACoA), it is common for even patients who have achieved a favourable neurological outcome to exhibit a significant number of emotional, behavioural and cognitive alterations. Despite preservation of a global cognitive performance, those patients frequently show deficits of memory, attention and executive functions, principally when intervention is surgical [1].
Herein is described the case of a man, 45 years old, who underwent open surgery following rupture of ACoA. After surgery the patient showed no sensory or motor disturbance. Global intelligence seemed intact. However, according to his relatives, he developed an inappropriate behaviour characterized by lack of planning, organization, problem solving and also poor decision-making deficits leading to important social, occupational and familial impairment. His first neuropsychological assessment was performed 48 months after the stroke. This assessment, regardless of the patient's normal intellectual global level of performance and the absence of visual and verbal memory deficits, demonstrated deficits of executive functions, attention and decision-making (Table 1). After this neuropsychological assessment, the patient was started on methylphenidate (dose progressively increased to 40 mg day−1) and another neuropsychological assessment was performed 6 months later, using the same battery of neuropsychological tasks. To avoid the practice effect of Iowa Gambling Task (IGT) we used two different versions (Win IGT and Lose IGT) described by Bechara et al. [3]. Executive functions, attention and decision-making abilities were improved on this second assessment, which was compatible with statements made by his relatives who communicated improvements in several aspects of his social, occupational and familial relationship. The patient's neuropsychological assessments were further compared with the performance of 10 healthy controls matched for age, sex and educational background (Table 1).
Neuropsychological tests
CD-AB, number of cards selected from the advantageous (C and D) decks minus the disadvantages (A and B) on IGT; FAS, words beginning with the letters F, A and S; IGT, Iowa Gambling Task; MF, methylphenidate.
Detailed description of neuropsychological tests are given in Spreen and Strauss [2] and Bechara et al. [3] for IGT.
This case illustrates the benefits of methylphenidate as a therapeutic option to treat the cognitive impairments of the present patient. The use of psychostimulants to ameliorate cognitive deficits of patients who suffer vascular cerebral diseases is still inconclusive and the literature has reported both positive [4] and negative [5] findings but the relationship between executive functions, attention and decision-making and frontal systems mediated by dopaminergic neurotransmission supports the use of psychostimulant drugs as methylphenidate to treat cognitive abilities in those cases [4]. However, double-blind randomized studies are needed to fully clarify the potentials and limitations of this drug in the cognition of neurologically impaired population.