Paroxysmal autonomic dysregulation with fever that was controlled by propranolol in a brain neoplasm patient

Clinical novel exploration of intractable fever in stroke rehabilitation: a single-center cross-sectional retrospective study

Fever has long been recognized as one of the earliest clinical indicators of illness and remains a leading reason for seeking medical care worldwide. It is typically classified based on its duration and underlying etiology. In clinical settings, intractable fever is as common as acute fever, particularly in patients with brain injuries. Beyond infectious causes, stroke survivors often experience recurrent intractable fever due to central or neurogenic mechanisms. This study aims to retrospectively investigate the incidence and clinical characteristics of acute and intractable fever in patients undergoing stroke rehabilitation. It explores the associations between these characteristics and the different types of fever. Additionally, the study seeks to identify potential risk factors contributing to the development of intractable fever, aiming to guide clinical management and optimize treatment strategies for stroke-related fever. This study evaluated 1,065 stroke patients in the rehabilitation phase who were admitted to the Neurorehabilitation Center between January 1, 2023, and December 31, 2023. Of these, 230 febrile patients met the inclusion criteria and were included in the analysis, comprising 194 cases of acute fever and 36 cases of intractable fever. Medical records and clinical characteristics were collected, and the data from the two groups of febrile patients were analyzed using t-tests, Mann-Whitney U tests, and chi-square tests. Logistic regression analysis was performed to identify risk factors associated with intractable fever, while receiver operating characteristic (ROC) curves were used to assess the predictive performance of individual and combined risk factors. A p-value of less than 0.05 was considered statistically significant. 15.7% of patients experienced intractable fever, which was significantly associated with brainstem lesions (P < 0.05). Compared to patients with acute fever, those with intractable fever had higher NIHSS scores (33.3% vs. 15.5%, P < 0.05), a greater incidence of consciousness disorders (66.7% vs. 28.9%, P < 0.05), and a higher rate of tracheostomy (55.6% vs. 15.5%, P < 0.05). All patients received antibiotic treatment, and gabapentin was administered to 16 cases. Patients with brainstem lesions were less likely to be treated with gabapentin (37.5% vs. 90%, P < 0.05), while those with intracerebral hemorrhage were more likely to receive gabapentin (87.5% vs. 10%, P < 0.05). Logistic regression analysis revealed that consciousness disorders and tracheostomy status were significant risk factors for intractable fever (P = 0.047, OR 6.691, 95% CI 1.030-43.478; P = 0.021, OR 5.366, 95% CI 1.282-22.465). Brainstem lesions also significantly increased the risk (P = 0.002, OR 9.617, 95% CI 2.277-40.614). Although limited in scope, this retrospective study highlights the increased risk of intractable fever during stroke rehabilitation among patients with consciousness disorders, tracheostomy, and brainstem injuries. The key risk factors identified include higher NIHSS scores, impaired consciousness, tracheostomy status, and brainstem lesions.

Neurogenic Fever in Severe Traumatic Brain Injury Treated with Propranolol: A Case Report

The causes of intractable fever in severe traumatic brain injury (TBI) patients can be diverse. Neurogenic fever (NF) which is a rare entity can develop due to autonomic dysregulation in the absence of infection or any other cause of fever. It manifests as fever, tachycardia, paroxysmal hypertension, dilated pupils, tachypnea, and extensor posturing in cases of severe TBI, brain neoplasms or brain haemorrhage. We found propranolol to be effective in controlling many of the manifestations of neurogenic fever in our patients with severe TBI. Fever in severe TBI patients is not an uncommon phenomenon, but when intractable with negative fever workup, a central cause should be considered. Propranolol is deemed as one of the most efficacious drugs for managing NF due to dysautonomia. We want to apprise the readers about this entity and its treatment with beta-blockers.

Morphine: An Effective Abortive Therapy for Pediatric Paroxysmal Sympathetic Hyperactivity After Hypoxic Brain Injury

Paroxysmal sympathetic hyperactivity (PSH) is a life-threatening condition characterized by hyperadrenergic activity and autonomic dysfunction. Also termed autonomic storms, PSH can occur after a variety of cerebral insults, most commonly traumatic brain injury. Limited pediatric literature is available, especially in patients with brain injury from hypoxia. No consensus exists for the terminology, diagnostic criteria, or treatment algorithm for PSH. Thus, the optimal management, including medication selection and dosing, remains unclear. We present the detailed treatment of a 9-year-old, African American male with hypoxic brain injury after pulseless arrest following status asthmaticus, who subsequently developed PSH. The patient began to experience episodes of tachycardia, hypertension, tachypnea, diaphoresis, rigidity, and dystonic posturing on hospital day 5. After ruling out other potential causes, a diagnosis of PSH was made. Episodes of PSH failed to respond to lorazepam or labetalol but were aborted successfully with morphine. Management of PSH after hypoxic brain injury required medications for acute treatment as well as for prevention of PSH. Morphine was found to be highly effective and safe for aborting the autonomic crises. Other agents more commonly described in the literature did not result in an adequate response and were associated with significant adverse effects. A combination of clonazepam, baclofen, and either propranolol or clonidine aided in reducing the frequency of episodes of PSH. We suggest using morphine for aborting severe episodes of PSH that do not respond to antihypertensive agents or benzodiazepines.

Propranolol for Paroxysmal Sympathetic Hyperactivity with Lateralizing Hyperhidrosis after Stroke

Brain injury can lead to impaired cortical inhibition of the hypothalamus, resulting in increased sympathetic nervous system activation. Symptoms of paroxysmal sympathetic hyperactivity may include hyperthermia, tachycardia, tachypnea, vasodilation, and hyperhidrosis. We report the case of a 41-year-old man who suffered from a left middle cerebral artery stroke and subsequently developed central fever, contralateral temperature change, and hyperhidrosis. His symptoms abated with low-dose propranolol and then returned upon discontinuation. Restarting propranolol again stopped his symptoms. This represents the first report of propranolol being used for unilateral dysautonomia after stroke. Propranolol is a lipophilic nonselective beta-blocker which easily crosses the blood-brain barrier and may be used to treat paroxysmal sympathetic hyperactivity.

A review of paroxysmal sympathetic hyperactivity after acquired brain injury

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.