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Wei Y, Cui Y, Pang X, Wang W. A systematic review and meta-analysis on abnormal posturing among brain injury patients. ARQUIVOS DE NEURO-PSIQUIATRIA 2024; 82:1-10. [PMID: 38653484 PMCID: PMC11039044 DOI: 10.1055/s-0044-1785689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 02/17/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Abnormal motor posturing (AMP), exhibiting as decorticate, decerebrate, or opisthotonos, is regularly noticed among children and adults. OBJECTIVE This systematic review and meta-analysis examined the risk factors and outcome of posturing among severe head and brain injury subjects. METHODS Based on the inclusion and exclusion criteria and using MeSH terms: "decerebrate posturing", "opisthotonic posturing", "brain injury", and/or "cerebral injury" articles were searched on Scopus, PubMed, Science Direct, and google scholar databases. Observational studies, case series, and case reports were included. RESULTS A total of 1953 studies were retrieved initially, and based on the selection criteria, 20 studies were finally selected for review and were analyzed for meta-analysis based on the mortality between the hematomas. The functional outcomes of this study are the risk factors, mortality rate and Glasgow Outcome Scale. Decerebrative patients were higher among the studies related to head injury surgeries. Males were mainly treated for decerebrate postures compared with the female subjects. Extradural hematoma and acute subdural hematoma with cerebral contusion were quite common in the surgical mass lesions. CONCLUSION The findings reported that the lesion types, the operative procedures, and the age of the decerebrating patients with brain injuries are the significant prognostic factors determining the survival outcomes.
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Affiliation(s)
- Yuyu Wei
- Hangzhou Red Cross Hospital, Department of Neurosurgery, Hangzhou, Zhejiang, People's Republic of China.
| | - Yan Cui
- Affiliated Hospital of North Sichuan Medical College, Department of Emergency, Shunqing, Sichuan, People's Republic of China.
| | - Xiaojun Pang
- Hangzhou Red Cross Hospital, Department of Neurosurgery, Hangzhou, Zhejiang, People's Republic of China.
| | - Weijie Wang
- Shandong University, The People's Hospital of Zhaoyuan City, Department of Neurosurgery, Zhaoyuan City, Shandong, People's Republic of China.
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Jang SH, Kwon HG. Relationship between hyperhidrosis and hypothalamic injury in patients with mild traumatic brain injury. Medicine (Baltimore) 2022; 101:e30574. [PMID: 36123888 PMCID: PMC9478253 DOI: 10.1097/md.0000000000030574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Hyperhidrosis is clinical symptom of various diseases and is an important clinical feature of paroxysmal sympathetic hyperactivity (PSH). Traumatic brain injury (TBI) is known to be most common condition associated with PSH, and PSH has been mainly reported in moderate and severe TBI. However, very little has been reported on PSH or hyperhidrosis in mild TBI patients. In this study, we used diffusion tensor imaging (DTI) to investigate the relationship between hyperhidrosis and hypothalamic injury in patients with mild TBI. Seven patients with hyperhidrosis after mild TBI and 21 healthy control subjects were recruited for this study. The Hyperhidrosis Disease Severity Scale was used for evaluation of sweating at the time of DTI scanning. The fractional anisotropy and apparent diffusion coefficient DTI parameters were measured in the hypothalamus. In the patient group, the fractional anisotropy values for both sides of the hypothalamus were significantly lower than those of the control group (P < .05). By contrast, the apparent diffusion coefficient values for both sides of the hypothalamus were significantly higher in the patient group than in the control group (P < .05). In conclusion, we detected hypothalamic injuries in patients who showed hyperhidrosis after mild TBI. Based on the results, it appears that hyperhidrosis in patients with mild TBI is related to hypothalamic injury.
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Affiliation(s)
- Sung Ho Jang
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University
| | - Hyeok Gyu Kwon
- Department of Physical Therapy, College of Health Science, Eulji University, Gyeonggi, Republic of Korea
- * Correspondence: Hyeok Gyu Kwon, PhD, Department of Physical Therapy, College of Health Science, Eulji University, Sansungdaero 533, Sujung-gu, Sungnam-si, Gyeonggi, 13135, Republic of Korea (e-mail: )
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Forstenpointner J, Elman I, Freeman R, Borsook D. The Omnipresence of Autonomic Modulation in Health and Disease. Prog Neurobiol 2022; 210:102218. [PMID: 35033599 DOI: 10.1016/j.pneurobio.2022.102218] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 12/13/2021] [Accepted: 01/10/2022] [Indexed: 10/19/2022]
Abstract
The Autonomic Nervous System (ANS) is a critical part of the homeostatic machinery with both central and peripheral components. However, little is known about the integration of these components and their joint role in the maintenance of health and in allostatic derailments leading to somatic and/or neuropsychiatric (co)morbidity. Based on a comprehensive literature search on the ANS neuroanatomy we dissect the complex integration of the ANS: (1) First we summarize Stress and Homeostatic Equilibrium - elucidating the responsivity of the ANS to stressors; (2) Second we describe the overall process of how the ANS is involved in Adaptation and Maladaptation to Stress; (3) In the third section the ANS is hierarchically partitioned into the peripheral/spinal, brainstem, subcortical and cortical components of the nervous system. We utilize this anatomical basis to define a model of autonomic integration. (4) Finally, we deploy the model to describe human ANS involvement in (a) Hypofunctional and (b) Hyperfunctional states providing examples in the healthy state and in clinical conditions.
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Affiliation(s)
- Julia Forstenpointner
- Center for Pain and the Brain, Boston Children's Hospital, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA, USA; Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Campus Kiel, SH, Germany.
| | - Igor Elman
- Center for Pain and the Brain, Boston Children's Hospital, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA, USA; Cambridge Health Alliance, Harvard Medical School, Cambridge, MA, USA
| | - Roy Freeman
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - David Borsook
- Center for Pain and the Brain, Boston Children's Hospital, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA, USA; Departments of Psychiatry and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Krishnan Y, Smitha B, Cholayil S. Paroxysmal Sympathetic Hyperactivity – An Under-Recognized Entity in Pediatric Brain Tumors: Case Report and Review of Literature. Indian J Med Paediatr Oncol 2020. [DOI: 10.4103/ijmpo.ijmpo_93_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
AbstractParoxysmal sympathetic hyperactivity (PSH) is not a well-recognized syndrome in pediatric brain tumors, but has been described in adults with traumatic brain injury. We describe the case of a child with medulloblastoma presenting with PSH. An index of suspicion is important in early diagnosis of PSH and this ultimately has an impact on the long-term outcome of patients with the syndrome.
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Affiliation(s)
- Yamini Krishnan
- Department of Paediatric Oncology, MVR Cancer Centre and Research Institute, Kozhikode (Calicut), Kerala, India
| | - B Smitha
- Department of Paediatric Oncology, MVR Cancer Centre and Research Institute, Kozhikode (Calicut), Kerala, India
| | - Shamsudheen Cholayil
- Department of Radiation Oncology, MVR Cancer Centre and Research Institute, Kozhikode (Calicut), Kerala, India
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Paroxysmal Sympathetic Hyperactivity: Diagnostic Criteria, Complications, and Treatment after Traumatic Brain Injury. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2018. [DOI: 10.1007/s40141-018-0175-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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6
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Tang Q, Wu X, Weng W, Li H, Feng J, Mao Q, Gao G, Jiang J. The preventive effect of dexmedetomidine on paroxysmal sympathetic hyperactivity in severe traumatic brain injury patients who have undergone surgery: a retrospective study. PeerJ 2017; 5:e2986. [PMID: 28229021 PMCID: PMC5314954 DOI: 10.7717/peerj.2986] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 01/12/2017] [Indexed: 11/20/2022] Open
Abstract
Background Paroxysmal sympathetic hyperactivity (PSH) results and aggravates in secondary brain injury, which seriously affects the prognosis of severe traumatic brain injury patients. Although several studies have focused on the treatment of PSH, few have concentrated on its prevention. Methods Ninety post-operation (post-op) severe traumatic brain injury (sTBI) patients admitted from October 2014 to April 2016 were chosen to participate in this study. Fifty of the post-op sTBI patients were sedated with dexmedetomidine and were referred as the “dexmedetomidine group” (admitted from May 2015 to April 2016). The other 40 patients (admitted from October 2014 to May 2015) received other sedations and were referred as the “control group.” The two groups were then compared based on their PSH scores and the scores and ratios of those patients who met the criteria of “probable,” “possible” and “unlikely” using the PSH assessment measure (PSH-AM) designed by Baguley et al. (2014). The durations of the neurosurgery intensive care unit (NICU) and hospital stays and the Glasgow outcome scale (GOS) values for the two groups were also compared to evaluate the therapeutic effects and the patients’ prognosis. Results The overall PSH score for the dexmedetomidine group was 5.26 ± 4.66, compared with 8.58 ± 8.09 for the control group. The difference between the two groups’ PSH scores was significant (P = 0.017). The score of the patients who met the criterion of “probable” was 18.33 ± 1.53 in the dexmedetomidine group and 22.63 ± 2.97 in the control group, and the difference was statistically significant (P = 0.045). The ratio of patients who were classified as “unlikely” between the two groups was statistically significant (P = 0.028); that is, 42 (84%) in the dexmedetomidine group and 25 (62.5%) in the control group. The differences in NICU, hospital stays and GOS values between the two groups were not significant. Conclusion Dexmedetomidine has a preventive effect on PSH in sTBI patients who have undergone surgery.
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Affiliation(s)
- Qilin Tang
- Department of Neurosurgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Institute of Head Trauma, Shanghai, China
| | - Xiang Wu
- Department of Neurosurgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Institute of Head Trauma, Shanghai, China
| | - Weiji Weng
- Department of Neurosurgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Institute of Head Trauma, Shanghai, China
| | - Hongpeng Li
- Department of Neurosurgery, Rizhao City Hospital of Traditional Chinese Medicine , Rizhao , Shandong Province , China
| | - Junfeng Feng
- Department of Neurosurgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Institute of Head Trauma, Shanghai, China
| | - Qing Mao
- Department of Neurosurgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Institute of Head Trauma, Shanghai, China
| | - Guoyi Gao
- Department of Neurosurgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Institute of Head Trauma, Shanghai, China
| | - Jiyao Jiang
- Department of Neurosurgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Institute of Head Trauma, Shanghai, China
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Olgun G, John E. Hypertension in the Pediatric Intensive Care Unit. J Pediatr Intensive Care 2016; 5:50-58. [PMID: 31110885 PMCID: PMC6512408 DOI: 10.1055/s-0035-1564796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 11/01/2014] [Indexed: 10/22/2022] Open
Abstract
Hypertension in the pediatric intensive care unit (PICU) is common and it contributes to the overall morbidity and mortality. Patients may present with hypertensive emergencies or hypertension can manifest itself later in PICU course. Although hypertension can be seen in most patients during hospitalization, patients with some specific diseases and conditions are more prone to hypertension. Hypertension should be recognized promptly and treated accordingly. Different pathophysiologic mechanisms can be responsible for the hypertension and management differs based on the underlying etiology. Any patient with a hypertensive emergency must be admitted to PICU, and treatment and diagnostic workup should be initiated immediately.
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Affiliation(s)
- Gokhan Olgun
- Department of Pediatric Critical Care Medicine, University of Chicago, Chicago, Illinois, United States
| | - Eunice John
- Department of Pediatric Nephrology, University of Illinois at Chicago, Illinois, United States
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8
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Lee S, Jun GW, Jeon SB, Kim CJ, Kim JH. Paroxysmal sympathetic hyperactivity in brainstem-compressing huge benign tumors: clinical experiences and literature review. SPRINGERPLUS 2016; 5:340. [PMID: 27064843 PMCID: PMC4792828 DOI: 10.1186/s40064-016-1898-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Accepted: 02/17/2016] [Indexed: 11/15/2022]
Abstract
Severe paroxysmal sympathetic overactivity occurs in a subgroup of patients with acquired brain injuries including traumatic brain injury, hypoxia, infection and tumor-related complications. This condition is characterized by sudden increase of heart rate, respiratory rate, blood pressure, body temperature and excessive diaphoresis. The episodes may be induced by external stimulation or may occur spontaneously. Frequent occurrence of this condition could result in secondary morbidities, therefore, should be diagnosed and managed insightfully. These symptoms could be confused with seizures or other medical conditions, leading to unnecessary treatment. Despite clinical significance of paroxysmal sympathetic hyperactivity (PSH), brain tumor-induced PSH has not been studied nearly. In this report, two cases of the PSH in patients with brainstem-compressing benign tumors were introduced. The most useful pharmacologic agents were opioid (e.g., fentanyl patch) in preventing PSH attack, and nonselective β-blocker (e.g., propranolol) in relieving the symptoms. Clinical experiences of the rare cases of benign tumor-induced PSH can be helpful as an essential basis for further research.
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Affiliation(s)
- Seungjoo Lee
- Department of Neurological Surgery, Asan Medical Center, College of Medicine, University of Ulsan, 388-1 Pungnab-dong, Songpa-gu, Seoul, 138-736 Republic of Korea
| | - Go Woon Jun
- Department of Anesthesia, Bestian Medical Center, Daejeon City, 300-060 Republic of Korea
| | - Sang Beom Jeon
- Department of Intensive Care Medicine, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, 138-736 Republic of Korea
| | - Chang Jin Kim
- Department of Neurological Surgery, Asan Medical Center, College of Medicine, University of Ulsan, 388-1 Pungnab-dong, Songpa-gu, Seoul, 138-736 Republic of Korea
| | - Jeong Hoon Kim
- Department of Neurological Surgery, Asan Medical Center, College of Medicine, University of Ulsan, 388-1 Pungnab-dong, Songpa-gu, Seoul, 138-736 Republic of Korea
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Kapoor D, Singla D, Singh J, Jindal R. Paroxysmal autonomic instability with dystonia (PAID) syndrome following cardiac arrest. Singapore Med J 2015; 55:e123-5. [PMID: 25189311 DOI: 10.11622/smedj.2013264] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Paroxysmal autonomic instability with dystonia (PAID) appears to be a unique syndrome following brain injury. It can echo many life-threatening conditions, making its early recognition and management a challenge for intensivists. A delay in early recognition and subsequent management may result in increased morbidity, which is preventable in affected patients. Herein, we report the case of a patient who was diagnosed with PAID syndrome following prolonged cardiac arrest, and discuss the pathophysiology, clinical presentation and management of this rare and under-recognised clinical entity.
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Affiliation(s)
- Dheeraj Kapoor
- Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India.
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10
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Abstract
PURPOSE OF REVIEW The autonomic nervous system functions to control heart rate, blood pressure, respiratory rate, gastrointestinal motility, hormone release, and body temperature on a second-to-second basis. Here we summarize some of the latest literature on autonomic dysfunction, focusing primarily on the perioperative implications. RECENT FINDINGS The variety of autonomic dysfunction now extends to a large number of clinical conditions in which the cause or effect of the autonomic component is blurred. Methods for detecting dysautonomia can be as simple as performing a history and physical examination that includes orthostatic vital signs measured in both recumbent and vertical positions; however, specialized laboratories are required for definitive diagnosis. Heart rate variability monitoring is becoming more commonplace in the assessment and understanding of autonomic instability. Degenerative diseases of the autonomic nervous system include Parkinson's disease and multiple system atrophy, with the most serious manifestations being postural hypotension and paradoxical supine hypertension. Other conditions occur in which the autonomic dysfunction is only part of a larger disease process, such as diabetic autonomic neuropathy, traumatic brain injury, and spinal cord injury. SUMMARY Patients with dysautonomia often have unpredictable and paradoxical physiological responses to various perioperative stimuli. Knowledge of the underlying pathophysiology of their condition is required in order to reduce symptom exacerbation and limit morbidity and mortality during the perioperative period.
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Baguley IJ, Perkes IE, Fernandez-Ortega JF, Rabinstein AA, Dolce G, Hendricks HT. Paroxysmal Sympathetic Hyperactivity after Acquired Brain Injury: Consensus on Conceptual Definition, Nomenclature, and Diagnostic Criteria. J Neurotrauma 2014; 31:1515-20. [DOI: 10.1089/neu.2013.3301] [Citation(s) in RCA: 172] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ian J. Baguley
- Brain Injury Rehabilitation Service, Westmead Hospital, Wentworthville, New South Wales, Australia
| | - Iain E. Perkes
- Department of Psychiatry, Royal Prince Alfred Hospital, Sydney, Australia
| | | | | | - Giuliano Dolce
- S. Anna Institute—Research in Advanced Neurorehabilitation, Crotone, Italy
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Romero FR, Zanini MA, Ducati LG, Gabarra RC. Sinking skin flap syndrome with delayed dysautonomic syndrome-An atypical presentation. Int J Surg Case Rep 2013; 4:1007-9. [PMID: 24083997 PMCID: PMC3825975 DOI: 10.1016/j.ijscr.2013.08.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Accepted: 08/26/2013] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Sinking skin flap syndrome or “syndrome of the trephined” is a rare complication after a large craniectomy, with a sunken skin above the bone defect with neurological symptoms such as severe headache, mental changes, focal deficits, or seizures. PRESENTATION OF CASE We report a case of 21 years old man with trefinated syndrome showing delayed dysautonomic changes. DISCUSSION Our patient had a large bone flap defect and a VP shunt that constitute risk factors to develop this syndrome. Also, there is reabsorption of bone tissue while it is placed in subcutaneous tissue. The principal symptoms of sinking skin flap syndrome are severe headache, mental changes, focal deficits, or seizures. Our patient presented with a delayed dysautonomic syndrome, with signs and symptoms very characteristics. Only few cases of this syndrome were related in literature and none were presented with dysautonomic syndrome. CONCLUSION We reported here a very uncommon case of sinking skill flap syndrome that causes a severe dysautonomic syndrome and worsening the patient condition.
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Affiliation(s)
- Flávio Ramalho Romero
- Division of Neurosurgery, Botucatu Medical School, São Paulo State University, UNESP, Botucatu, Brazil; Hospital das Clínicas, UNESP, Botucatu, Brazil.
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Choi HA, Jeon SB, Samuel S, Allison T, Lee K. Paroxysmal Sympathetic Hyperactivity After Acute Brain Injury. Curr Neurol Neurosci Rep 2013; 13:370. [DOI: 10.1007/s11910-013-0370-3] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Hoarau X, Richer E, Dehail P, Cuny E. Comparison of long-term outcomes of patients with severe traumatic or hypoxic brain injuries treated with intrathecal baclofen therapy for dysautonomia. Brain Inj 2012; 26:1451-63. [DOI: 10.3109/02699052.2012.694564] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Hoarau X, Richer E, Dehail P, Cuny E. A 10-year follow-up study of patients with severe traumatic brain injury and dysautonomia treated with intrathecal baclofen therapy. Brain Inj 2012; 26:927-40. [DOI: 10.3109/02699052.2012.661913] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
BACKGROUND Dysautonomia after severe traumatic brain injury (TBI) is a clinical syndrome affecting a subgroup of survivors and is characterized by episodes of autonomic dysregulation and muscle overactivity. The purpose of this study was to determine the incidence of dysautonomia after severe TBI in an intensive care unit setting and analyze the risk factors for developing dysautonomia. METHODS A consecutive series of 101 patients with severe TBI admitted in a major trauma hospital during a 2-year period were prospectively observed to determine the effects of age, sex, mode of injury, hypertension history, admission systolic blood pressure, fracture, lung injury, admission Glasgow Coma Scale (GCS) score, injury severity score, emergency craniotomy, sedation or analgesia, diffuse axonal injury (DAI), magnetic resonance imaging (MRI) scales, and hydrocephalus on the development of dysautonomia. Risk factors for dysautonomia were evaluated by using logistic regression analysis. RESULTS Seventy-nine of the 101 patients met inclusion criteria, and dysautonomia was observed in 16 (20.3%) of these patients. Univariate analysis revealed significant correlations between the occurrence of dysautonomia and patient age, admission GCS score, DAI, MRI scales, and hydrocephalus. Sex, mode of injury, hypertension history, admission systolic blood pressure, fracture, lung injury, injury severity score, sedation or analgesia, and emergency craniotomy did not influence the development of dysautonomia. Multivariate logistic regression revealed that patient age and DAI were two independent predictors of dysautonomia. There was no independent association between dysautonomia and admission GCS score, MRI scales, or hydrocephalus. CONCLUSIONS Dysautonomia frequently occurs in patients with severe TBI. A younger age and DAI could be risk factors for facilitating the development of dysautonomia.
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Kirkham FJ, Haywood P, Kashyape P, Borbone J, Lording A, Pryde K, Cox M, Keslake J, Smith M, Cuthbertson L, Murugan V, Mackie S, Thomas NH, Whitney A, Forrest KM, Parker A, Forsyth R, Kipps CM. Movement disorder emergencies in childhood. Eur J Paediatr Neurol 2011; 15:390-404. [PMID: 21835657 DOI: 10.1016/j.ejpn.2011.04.005] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2011] [Accepted: 04/17/2011] [Indexed: 12/27/2022]
Abstract
The literature on paediatric acute-onset movement disorders is scattered. In a prospective cohort of 52 children (21 male; age range 2mo-15y), the commonest were chorea, dystonia, tremor, myoclonus, and Parkinsonism in descending order of frequency. In this series of mainly previously well children with cryptogenic acute movement disorders, three groups were recognised: (1) Psychogenic disorders (n = 12), typically >10 years of age, more likely to be female and to have tremor and myoclonus (2) Inflammatory or autoimmune disorders (n = 22), including N-methyl-d-aspartate receptor encephalitis, opsoclonus-myoclonus, Sydenham chorea, systemic lupus erythematosus, acute necrotizing encephalopathy (which may be autosomal dominant), and other encephalitides and (3) Non-inflammatory disorders (n = 18), including drug-induced movement disorder, post-pump chorea, metabolic, e.g. glutaric aciduria, and vascular disease, e.g. moyamoya. Other important non-inflammatory movement disorders, typically seen in symptomatic children with underlying aetiologies such as trauma, severe cerebral palsy, epileptic encephalopathy, Down syndrome and Rett syndrome, include dystonic posturing secondary to gastro-oesophageal reflux (Sandifer syndrome) and Paroxysmal Autonomic Instability with Dystonia (PAID) or autonomic 'storming'. Status dystonicus may present in children with known extrapyramidal disorders, such as cerebral palsy or during changes in management e.g. introduction or withdrawal of neuroleptic drugs or failure of intrathecal baclofen infusion; the main risk in terms of mortality is renal failure from rhabdomyolysis. Although the evidence base is weak, as many of the inflammatory/autoimmune conditions are treatable with steroids, immunoglobulin, plasmapheresis, or cyclophosphamide, it is important to make an early diagnosis where possible. Outcome in survivors is variable. Using illustrative case histories, this review draws attention to the practical difficulties in diagnosis and management of this important group of patients.
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Affiliation(s)
- F J Kirkham
- Southampton University Hospitals NHS Trust, UK.
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Perkes IE, Menon DK, Nott MT, Baguley IJ. Paroxysmal sympathetic hyperactivity after acquired brain injury: A review of diagnostic criteria. Brain Inj 2011; 25:925-32. [DOI: 10.3109/02699052.2011.589797] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Sung HJ, Sohn JT, Kim JG, Shin IW, Ok SH, Lee HK, Chung YK. Acute respiratory alkalosis occurring after endoscopic third ventriculostomy -A case report-. Korean J Anesthesiol 2011; 59 Suppl:S194-6. [PMID: 21286439 PMCID: PMC3030035 DOI: 10.4097/kjae.2010.59.s.s194] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Revised: 05/03/2010] [Accepted: 05/26/2010] [Indexed: 11/24/2022] Open
Abstract
An endoscopic third ventriculostomy was performed in a 55-year-old man with an obstructive hydrocephalus due to aqueductal stenosis. The vital signs and laboratory studies upon admission were within the normal limits. Anesthesia was maintained with nitrous oxide in oxygen and 6% desflurane. The patient received irrigation with approximately 3,000 ml normal saline during the procedure. Anesthesia and operation were uneventful. However, he developed postoperative hyperventilation in the recovery room, and arterial blood gas analysis revealed acute respiratory alkalosis. We report a rare respiratory alkalosis that occurred after an endoscopic third ventriculostomy.
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Affiliation(s)
- Hui-Jin Sung
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University School of Medicine, Jinju, Korea
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Sympathetic Hyperactivity After Traumatic Brain Injury and the Role of Beta-Blocker Therapy. ACTA ACUST UNITED AC 2010; 69:1602-9. [DOI: 10.1097/ta.0b013e3181f2d3e8] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Perkes I, Baguley IJ, Nott MT, Menon DK. A review of paroxysmal sympathetic hyperactivity after acquired brain injury. Ann Neurol 2010; 68:126-35. [PMID: 20695005 DOI: 10.1002/ana.22066] [Citation(s) in RCA: 199] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Severe excessive autonomic overactivity occurs in a subgroup of people surviving acquired brain injury, the majority of whom show paroxysmal sympathetic and motor overactivity. Delayed recognition of paroxysmal sympathetic hyperactivity (PSH) after brain injury may increase morbidity and long-term disability. Despite its significant clinical impact, the scientific literature on this syndrome is confusing; there is no consensus on nomenclature, etiological information for diagnoses preceding the condition is poorly understood, and the evidence base underpinning our knowledge of the pathophysiology and management strategies is largely anecdotal. This systematic literature review identified 2 separate categories of paroxysmal autonomic overactivity, 1 characterized by relatively pure sympathetic overactivity and another group of disorders with mixed parasympathetic/sympathetic features. The PSH group comprised 349 reported cases, with 79.4% resulting from traumatic brain injury (TBI), 9.7% from hypoxia, and 5.4% from cerebrovascular accident. Although TBI is the dominant causative etiology, there was some suggestion that the true incidence of the condition is highest following cerebral hypoxia. In total, 31 different terms were identified for the condition. Although the most common term in the literature was dysautonomia, the consistency of sympathetic clinical features suggests that a more specific term should be used. The findings of this review suggest that PSH be adopted as a more clinically relevant and appropriate term. The review highlights major problems regarding conceptual definitions, diagnostic criteria, and nomenclature. Consensus on these issues is recommended as an essential basis for further research in the area.
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Kim CT, Moberg-Wolff E, Trovato M, Kim H, Murphy N. Pediatric rehabilitation: 1. Common medical conditions in children with disabilities. PM R 2010; 2:S3-S11. [PMID: 20359677 DOI: 10.1016/j.pmrj.2009.12.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2009] [Accepted: 12/09/2009] [Indexed: 11/18/2022]
Abstract
OBJECTIVE This self-directed learning module focuses on the physiatric management of the common morbidities associated with pediatric traumatic brain injury and cerebral palsy. It is part of the study guide on pediatric rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation and pediatric medicine. The goal of this article is to enhance the learner's knowledge regarding current physiatric management of complications related with pediatric traumatic brain injury and cerebral palsy.
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Affiliation(s)
- Chong Tae Kim
- Department of PM&R, University of Pennsylvania, School of Medicine, 3405 Civic Center Boulevard, Philadelphia, PA 19096, USA.
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Baguley IJ, Heriseanu RE, Felmingham KL, Cameron ID. Dysautonomia and heart rate variability following severe traumatic brain injury. Brain Inj 2009; 20:437-44. [PMID: 16716989 DOI: 10.1080/02699050600664715] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PRIMARY OBJECTIVE To investigate disconnection theories postulated as the cause of dysautonomia following severe traumatic brain injury (TBI) through analysis of heart rate variability (HRV). METHODS AND PROCEDURES Data were collected on age-matched subjects with and without dysautonomia (eight subjects in each group) and 16 non-injured controls. Data included injury details, continuous electrocardiograph recordings and rehabilitation outcome. MAIN OUTCOMES AND RESULTS The TBI group revealed significant differences in HRV parameters both compared to controls and between dysautonomic and non-dysautonomic subjects. Additionally, HRV parameters for dysautonomic subjects showed evidence of an uncoupling of the normal relationship between heart rate and sympathetic/parasympathetic balance. HRV changes persisted for the dysautonomia group for a mean of 14 months post-injury. CONCLUSIONS Dysautonomic subjects revealed prolonged uncoupling of heart rate and HRV parameters compared to non-dysautonomic subjects and controls. These findings represent direct pathophysiological evidence supporting the disconnection theory postulated to produce dysautonomia following TBI.
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Affiliation(s)
- Ian J Baguley
- Brain Injury Rehabilitation Service, Westmead Hospital, Westmead, NSW, Australia.
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De Tanti A, Gasperini G, Rossini M. Paroxysmal episodic hypothalamic instability with hypothermia after traumatic brain injury. Brain Inj 2009; 19:1277-83. [PMID: 16286344 DOI: 10.1080/02699050500309270] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
This case report describes a patient in vegetative state after severe traumatic brain injury (TBI) with hypothalamic damage and clinical manifestations of autonomic dysfunction. He also presented late onset paroxysmal hypothermia associated with mild bradycardia and hypotension. Hypothermia due to traumatic lesions of the hypothalamus is an uncommon clinical problem and few cases have been reported; no cases could be found in the literature which evidenced periodic hypothermia associated with clinical features of autonomic dysfunction after TBI. In the article, the main causes and the primary pathophysiology of hypothermia after TBI are discussed. The manifestations in this patient have been interpreted as possible consequences of autonomic dysfunction and considered atypical and rare clinical expression of acute post-traumatic hypothalamic instability.
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Affiliation(s)
- Antonio De Tanti
- Department of Rehabilitation Medicine, Ospedale Valduce, Villa Beretta, Costamasnaga, Lecco, Italy.
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Baguley IJ, Cameron ID, Green AM, Slewa-Younan S, Marosszeky JE, Gurka JA. Pharmacological management of Dysautonomia following traumatic brain injury. Brain Inj 2009; 18:409-17. [PMID: 15195790 DOI: 10.1080/02699050310001645775] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PRIMARY OBJECTIVE To document and critically evaluate the likely effectiveness of pharmacological treatments used in a sample of patients with Dysautonomia and to link these findings to previously published literature. RESEARCH DESIGN Retrospective case control chart review. METHODS AND PROCEDURES Data were collected on age, sex and GCS matched subjects with and without Dysautonomia (35 cases and 35 controls). Data included demographic and injury details, physiological parameters, medication usage, clinical progress and rehabilitation outcome. Descriptive analyses were undertaken to characterize the timing and frequency of CNS active medications. MAIN OUTCOMES AND RESULTS Dysautonomic patients were significantly more likely to receive neurologically active medications. A wide variety of drugs were utilised with the most frequent being morphine/midazolam and chlorpromazine. Cessation of morphine/midazolam produced significant increases in heart rate and respiratory rate but not temperature. Chlorpromazine may have modified respiratory rate responses, but not temperature or heart rate. CONCLUSIONS The features of Dysautonomia are similar to a number of conditions treated as medical emergencies. Despite this, no definitive treatment paradigm exists. The best available evidence is for morphine (especially intravenously), benzodiazepines, propanolol, bromocriptine and possibly intrathecal baclofen. Barriers to improving management include the lack of a standardized nomenclature, formal definition or accepted diagnostic test. Future research needs to be conducted to improve understanding of Dysautonomia with a view to minimizing disability.
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Affiliation(s)
- Ian J Baguley
- Brain Injury Rehabilitation Service, Westmead Hospital, Wentworthville, NSW, Australia.
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Childs C, Jones AKP, Tyrrell PJ. Long-term temperature-related morbidity after brain damage: survivor-reported experiences. Brain Inj 2008; 22:603-9. [PMID: 18568714 DOI: 10.1080/02699050802189719] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PRIMARY OBJECTIVE To determine whether temperature-related symptoms exist, long-term, in survivors of brain damage. RESEARCH DESIGN Scoping exercise. METHODS AND PROCEDURES A 'call for information', posted in the quarterly News bulletins of two major UK brain injury support groups, about any current or past temperature-related symptoms or problems that had developed since onset of brain damage. MAIN OUTCOMES AND RESULTS Narratives from 41 survivors revealed the nature of temperature-related morbidity, ongoing, on average, for 8 years since brain damage. Twenty-five survivors reported problems specifically related to feelings of extreme heat; in a further eight, heat-related problems occurred with bouts of 'cold'. Feelings of extreme cold only were less common (n = 8). In 20 survivors, temperature problems had adverse effects on health and personal and social relationships. CONCLUSIONS To the authors' knowledge, this is the first account of temperature-related problems in the form of narratives from survivors of a variety of brain injuries. The origin of abnormal somatic sensibility to temperature is currently unclear. It is plausible that the symptoms could be a 'variant' of the 'pain-thermoregulatory distress axis' well described after human stroke. In the meantime, apparently abnormal sensory and physical symptoms experienced by the survivors lack both explanation and remedy.
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Affiliation(s)
- Charmaine Childs
- Clinical Neurosciences, School of Translational Medicine, University of Manchester, Salford, UK.
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Recognition of Paroxysmal Autonomic Instability With Dystonia (PAID) in a Patient With Traumatic Brain Injury. ACTA ACUST UNITED AC 2008; 64:500-2. [DOI: 10.1097/ta.0b013e31804a5738] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Baguley IJ. The excitatory:inhibitory ratio model (EIR model): An integrative explanation of acute autonomic overactivity syndromes. Med Hypotheses 2008; 70:26-35. [PMID: 17583440 DOI: 10.1016/j.mehy.2007.04.037] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2007] [Accepted: 04/25/2007] [Indexed: 12/21/2022]
Abstract
Numerous medical conditions present with acute and severe autonomic and muscular overactivity. These syndromes include Neuroleptic Malignant Syndrome, Serotonin Syndrome, Dysautonomia (or paroxysmal sympathetic storms) following acquired brain injury, Autonomic Dysreflexia, Parkinsonian-Hyperpyrexia Syndrome, Malignant Catatonia, intrathecal baclofen withdrawal, Malignant Hyperthermia, Stiff Man Syndrome and Irukandji Syndrome. In their worst forms, each of these syndromes are relatively rare, are treated by different medical specialties and show widely varying pathophysiology. Most are considered to be medical emergencies and share significant mortality rates. Previous authors have noted similarities between some of these conditions, prompting the suggestion that a single common mechanism may underlie their clinical presentation. However, the development of such an integrative model has not occurred. This paper presents a short review of the clinical syndromes, grouped by the location of pathology and mechanism of action. From this background, an integrative framework termed the excitatory:inhibitory ratio (EIR) model is presented. The EIR model consists of two inter-related networks operating at spinal and brainstem levels. The model is evaluated against pre-clinical scientific research, known pathways, each disorder's pathophysiology (where this is known) and variable severity, and used to explain the reasons behind the efficacy of current treatment regimes. Circumstantial evidence for an expanded aetiology for Malignant Hyperthermia is provided and generic treatment strategies for a number of other conditions are suggested. Finally, minor modifications to this model provide a basis to begin to explain less severe, regional "overlap" syndromes.
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Affiliation(s)
- Ian J Baguley
- Brain Injury Rehabilitation Service, Westmead Hospital, P.O. Box 533, Westmead, Wentworthville, NSW 2145, Australia.
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Baguley IJ, Heriseanu RE, Cameron ID, Nott MT, Slewa-Younan S. A Critical Review of the Pathophysiology of Dysautonomia Following Traumatic Brain Injury. Neurocrit Care 2007; 8:293-300. [DOI: 10.1007/s12028-007-9021-3] [Citation(s) in RCA: 126] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Gil Antón J, López Bayón J, López Fernández Y, Pilar Orive J. [Autonomic dysfunction syndrome secondary to tuberculous meningitis]. An Pediatr (Barc) 2005; 61:449-50. [PMID: 15530332 DOI: 10.1016/s1695-4033(04)78427-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Baguley IJ, Nicholls JL, Felmingham KL, Crooks J, Gurka JA, Wade LD. Dysautonomia after traumatic brain injury: a forgotten syndrome? J Neurol Neurosurg Psychiatry 1999; 67:39-43. [PMID: 10369820 PMCID: PMC1736437 DOI: 10.1136/jnnp.67.1.39] [Citation(s) in RCA: 135] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To better establish the clinical features, natural history, clinical management, and rehabilitation implications of dysautonomia after traumatic brain injury, and to highlight difficulties with previous nomenclature. METHODS Retrospective file review on 35 patients with dysautonomia and 35 sex and Glasgow coma scale score matched controls. Groups were compared on injury details, CT findings, physiological indices, and evidence of infections over the first 28 days after injury, clinical progress, and rehabilitation outcome. RESULTS the dysautonomia group were significantly worse than the control group on all variables studied except duration of stay in intensive care, the rate of clinically significant infections found, and changes in functional independence measure (FIM) scores. CONCLUSIONS Dysautonomia is a distinct clinical syndrome, associated with severe diffuse axonal injury and preadmission hypoxia. It is associated with a poorer functional outcome; however, both the controls and patients with dysautonomia show a similar magnitude of improvement as measured by changes in FIM scores. It is argued that delayed recognition and treatment of dysautonomia results in a preventable increase in morbidity.
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Affiliation(s)
- I J Baguley
- Brain Injury Rehabilitation Service, Westmead Hospital, Westmead, NSW 2145, Australia.
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Scott JS, Ockey RR, Holmes GE, Varghese G. Autonomic dysfunction associated with locked-in syndrome in a child. Am J Phys Med Rehabil 1997; 76:200-3. [PMID: 9207704 DOI: 10.1097/00002060-199705000-00007] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This is a report of a young boy with the unusual combination of autonomic dysfunction with locked-in syndrome following multiple shunt revisions for hydrocephalus. A review of the literature on autonomic dysfunction syndrome and the complex clinical picture of the combined syndromes in a pediatric patient are discussed. The marked effectiveness of treatment with carbidopa/levodopa over bromocriptine for both syndromes is noted.
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Affiliation(s)
- J S Scott
- Tulsa Developmental Pediatrics and Center of Family Psychology, Oklahoma, USA
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Sneed RC. Hyperpyrexia associated with sustained muscle contractions: an alternative diagnosis to central fever. Arch Phys Med Rehabil 1995; 76:101-3. [PMID: 7811167 DOI: 10.1016/s0003-9993(95)80051-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Muscle activity is the principal source of body heat production, and elevated core body temperatures may occur in healthy exercising persons. Hyperpyrexia from sustained tonic muscle contractions can also occur in a number of pathological conditions. The present case of hyperpyrexia associated with dystonic posturing and sustained muscle contraction in a child with encephalopathy illustrates the importance of recognizing muscular activity in the generation of fever of unknown origin following central nervous system injury. The pathophysiology, clinical features, and management of this uncommon cause of fever are discussed.
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Affiliation(s)
- R C Sneed
- Ohio State University, Department of Physical Medicine and Rehabilitation, Columbus
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Meythaler JM, Stinson AM. Fever of central origin in traumatic brain injury controlled with propranolol. Arch Phys Med Rehabil 1994. [DOI: 10.1016/0003-9993(94)90143-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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