1401 - Paradoxical (?) effect of methylphenidate on appetite in the hypoaroused patient with brain injury

Case Diagnosis: post-stroke anorexia

Case Description: A 60-year-old female presented for inpatient rehabilitation after a subarachnoid hemorrhage due to a posterior communicating artery aneurysm rupture. At admission, she was hypoaroused with poor appetite and dysphagia, requiring tube feedings. CT head showed mild ventriculomegaly, inconclusive for hydrocephalus. Persistently elevated blood pressure was treated with propranolol. Appetite remained poor despite improved swallowing, eating < 25% of meals. A stimulant trial was considered for hypoarousal but propranolol needed to be discontinued first. During the propranolol taper, appetite improved but hypoarousal persisted. A methylphenidate trial subsequently improved arousal with even further improvement in appetite. At discharge, she was alert, participating in all therapies and eating 100% of her meals, allowing removal of her feeding tube.

Discussions: Optimizing nutrition is important for neurocritical patients with acquired brain injury. Nutritional intake can be influenced by several factors, including level of consciousness, ability to swallow, motor strength, and concurrent gastrointestinal or infectious complications. Medications can also influence oral intake, with noradrenergic agonists notably being associated with anorexic side effects. In this patient, noradrenergic drug administration showed a clear association with arousal. This was evidenced by initial improvement in arousal with tapering propranolol followed by arousal normalization during the methylphenidate trial. Increased oral intake appeared to coincide with enhanced arousal. This potentially explains the paradoxical observation of improved oral intake during the methylphenidate trial.

Conclusions: Patients with severe acquired brain injury may manifest impaired arousal with compromised oral intake. Improved arousal often coincides with better appetite. In appropriately selected patients with impaired arousal after an acquired brain injury, noradrenergic stimulants may have a role in improved oral intake.