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Ott JL, Watanabe TK. Evaluation and Pharmacologic Management of Paroxysmal Sympathetic Hyperactivity in Traumatic Brain Injury. J Head Trauma Rehabil 2024:00001199-990000000-00158. [PMID: 38833717 DOI: 10.1097/htr.0000000000000960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
OBJECTIVE Paroxysmal sympathetic hyperactivity (PSH) can occur in up to 10% of severe traumatic brain injury (TBI) patients and is associated with poorer outcomes. A consensus regarding management is lacking. We provide a practical guide on the multi-faceted clinical management of PSH, including pharmacological, procedural and non-pharmacological interventions. In addition to utilizing a standardized assessment tool, the use of medications to manage sympathetic and musculoskeletal manifestations (including pain) is highlighted. Recent studies investigating new approaches to clinical management are included in this review of pharmacologic treatment options. CONCLUSION While studies regarding pharmacologic selection for PSH are limited, this paper suggests a clinical approach to interventions based on predominant symptom presentation (sympathetic hyperactivity, pain and/or muscle hypertonicity) and relevant medication side effects.
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Affiliation(s)
- Jamie L Ott
- Author Affiliations: Department of Physical Medicine and Rehabilitation, University of Washington, Seattle, WA, (Dr Ott); and Drucker Brain Injury Center, Stroke Rehabilitation Program, Jefferson Moss-Magee Rehabilitation, Elkins Park, PA, (Dr Watanabe)
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2
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Li X, Yang X, Yu T, Zhang T, Tang Y. Paroxysmal sympathetic hyperexcitability after brain injury: A clinical analysis of case series. Medicine (Baltimore) 2024; 103:e35375. [PMID: 38758899 PMCID: PMC11098178 DOI: 10.1097/md.0000000000035375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 09/04/2023] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Paroxysmal sympathetic hyperexcitability (PSH) is a group of complex syndromes with various etiologies. Previous studies were limited to the description of traumatic brain injury (TBI), and the description of PSH after other types of brain injury was rare. We explored the clinical features, treatment, and prognosis of PSH after various types of brain injuries. METHODS Patients admitted to the neurosurgery intensive care unit with PSH after brain injury from July 2019 to December 2022 were included. Demographic data, clinical manifestations, drug therapy, and disease prognosis were retrospectively collected and analyzed. RESULTS Fifteen male and 9 female patients with PSH after brain injury were selected. TBI was most likely to cause PSH (66.7%), followed by spontaneous intracerebral hemorrhage (25%). Glasgow coma scale scores of 19 patients (79.2%) were lower than 8 and 14 patients (58.3%) underwent tracheotomy. Electroencephalogram monitoring was performed in 12 individuals, none of which showed epileptic waves. Clinical symptom scale showed mild symptoms in 17 cases (70.8%). Almost all patients were administered a combination of drugs. After follow-up, most patients had a poor prognosis and 2 (8.3%) died after discharge. CONCLUSION The etiology of PSH is complex. TBI may be the most common cause of PSH. Non-TBI may also be an important cause of PSH. Therefore, early identification, prevention and diagnosis are helpful for determining the prognosis and outcome of the disease.
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Affiliation(s)
- Xingru Li
- Department of Neurosurgery, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), Wuhu, China
| | - Xinchen Yang
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Tao Yu
- Department of Neurosurgery, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), Wuhu, China
| | - Tiqiang Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), Wuhu, China
| | - Yun Tang
- Department of Neurosurgery, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), Wuhu, China
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Xu SY, Zhang Q, Li CX. Paroxysmal Sympathetic Hyperactivity After Acquired Brain Injury: An Integrative Review of Diagnostic and Management Challenges. Neurol Ther 2024; 13:11-20. [PMID: 37948005 PMCID: PMC10787720 DOI: 10.1007/s40120-023-00561-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/23/2023] [Indexed: 11/12/2023] Open
Abstract
Paroxysmal sympathetic hyperactivity (PSH) mainly occurs after acquired brain injury (ABI) and often presents with high fever, hypertension, tachycardia, tachypnea, sweating, and dystonia (increased muscle tone or spasticity). The pathophysiological mechanisms of PSH are not fully understood. Currently, there are several views: (1) disconnection theory, (2) excitatory/inhibitory ratio, (3) neuroendocrine function, and (4) neutrophil extracellular traps. Early diagnosis of PSH remains difficult, given the low specificity of its diagnostic tools and unclear pathogenesis. According to updated case analyses in recent years, PSH is now more commonly observed in patients with stroke, with tachycardia and hypertension as the main clinical manifestations, which is not fully consistent with previous data. To date, the PSH Assessment Measure tool is optimal for the early identification of PSH and stratification of symptom severity. Clinical strategies for the management of PSH are divided into three main points: (1) reduction of stimulation, (2) reduction of sympathetic excitatory afferents, and (3) inhibition of the effects of sympathetic hyperactivity on target organs. However, use of drugs and standards have not yet been harmonized. Further investigation on the relationship between PSH severity and long-term neurological prognosis in patients with ABI is required. This review aimed to determine the diagnostic and management challenges encountered in PSH after ABI.
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Affiliation(s)
- Sui-Yi Xu
- Department of Neurology, Headache Center, The First Hospital of Shanxi Medical University, Jiefangnan 85 Road, 030001, Taiyuan, Shanxi, People's Republic of China
| | - Qi Zhang
- Department of Neurology, Headache Center, The First Hospital of Shanxi Medical University, Jiefangnan 85 Road, 030001, Taiyuan, Shanxi, People's Republic of China
| | - Chang-Xin Li
- Department of Neurology, Headache Center, The First Hospital of Shanxi Medical University, Jiefangnan 85 Road, 030001, Taiyuan, Shanxi, People's Republic of China.
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Li LM, Carson A, Dams-O'Connor K. Psychiatric sequelae of traumatic brain injury - future directions in research. Nat Rev Neurol 2023; 19:556-571. [PMID: 37591931 DOI: 10.1038/s41582-023-00853-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2023] [Indexed: 08/19/2023]
Abstract
Despite growing appreciation that traumatic brain injury (TBI) is an important public health burden, our understanding of the psychiatric and behavioural consequences of TBI remains limited. These changes are particularly detrimental to a person's sense of self, their relationships and their participation in the wider community, and they continue to have devastating individual and cumulative effects long after TBI. This Review relates specifically to TBIs that confer objective clinical or biomarker evidence of structural brain injury; symptomatic head injuries without such evidence are outside the scope of this article. Common psychiatric, affective and behavioural sequelae of TBI and their proposed underlying mechanisms are outlined, along with a brief overview of current treatments. Suggestions for how scientists and clinicians can work together in the future to address the chasms in clinical care and knowledge are discussed in depth.
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Affiliation(s)
- Lucia M Li
- Department of Brain Sciences, Imperial College London, London, UK.
| | - Alan Carson
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Kristen Dams-O'Connor
- Brain Injury Research Center, Department of Rehabilitation and Human Performance, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Miao H, Huang H, Chen W, Su YY, Zhang Y. Clinical characteristics and prognosis of paroxysmal sympathetic hyperactivity in patients with severe nontraumatic brain injury. Brain Inj 2023; 37:95-100. [PMID: 36662125 DOI: 10.1080/02699052.2023.2165151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE This prospective study investigated and analyzed the clinical characteristics and prognosis of paroxysmal sympathetic hyperactivity (PSH) in patients with severe nontraumatic brain injury. METHODS Patients presenting with severe nontraumatic brain injury with PSH from July 2018 to June 2019 were enrolled. A PSH assessment measure ≥ 8 points was used as the criterion for PSH. Clinical data, indicators related to PSH, treatment effects and the prognosis were prospectively collected and analyzed. RESULTS A total of 220 patients with severe nontraumatic brain injury were analyzed, and PSH occurred in 8 patients (3.6%). The primary neurological diseases included acute cerebral infarction, anti-N-methyl-D-aspartate receptor encephalitis, hypoxic encephalopathy and acute disseminated encephalitis. The Glasgow Coma Scale score was lower than 8 in the 8 patients with PSH. Seven of these eight patients had a Glasgow outcome scale (GOS) score of 3 or less than 3, and one patient had a GOS of 5 after 6 months. The medicines that effectively controlled PSH included dexmedetomidine, clonazepam, midazolam and diazepam. CONCLUSIONS Although the incidence was lower for nontraumatic brain injury complicated with PSH than for traumatic brain injury, patients with PSH had a more severe disease state and poorer prognoses. Dexmedetomidine might effectively control PSH.
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Affiliation(s)
- He Miao
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Department of Neurointensive Care Unit, Central Hospital of Henan Sanmenxia, Henan, China
| | - Huijin Huang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Weibi Chen
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ying-Ying Su
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yan Zhang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
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6
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Wang H, Li Y, Zhao M, Ren C, Zhang S. The effects of hyperbaric oxygen therapy on paroxysmal sympathetic hyperactivity after cardiopulmonary resuscitation: a case series. World J Emerg Med 2023; 14:477-480. [PMID: 37969219 PMCID: PMC10632763 DOI: 10.5847/wjem.j.1920-8642.2023.092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 06/02/2023] [Indexed: 11/17/2023] Open
Affiliation(s)
- Hongyu Wang
- Department of Emergency Medicine, the Fifth Clinical Medical College of Henan University of Chinese Medicine, Zhengzhou 450003, China
- Department of Emergency Medicine, People’s Hospital of Henan University of Chinese Medicine/People’s Hospital of Zhengzhou, Zhengzhou 450003, China
- Henan Research Centre of Cardiopulmonary-Cerebral Resuscitation Engineering Technology, Zhengzhou 450003, China
| | - Yihao Li
- Department of Emergency Medicine, the Fifth Clinical Medical College of Henan University of Chinese Medicine, Zhengzhou 450003, China
- Henan Research Centre of Cardiopulmonary-Cerebral Resuscitation Engineering Technology, Zhengzhou 450003, China
| | - Meng Zhao
- Department of Emergency Medicine, People’s Hospital of Henan University of Chinese Medicine/People’s Hospital of Zhengzhou, Zhengzhou 450003, China
| | - Caihong Ren
- Department of Emergency Medicine, Luohe Central Hospital, Luohe 462000, China
| | - Sisen Zhang
- Department of Emergency Medicine, the Fifth Clinical Medical College of Henan University of Chinese Medicine, Zhengzhou 450003, China
- Department of Emergency Medicine, People’s Hospital of Henan University of Chinese Medicine/People’s Hospital of Zhengzhou, Zhengzhou 450003, China
- Henan Research Centre of Cardiopulmonary-Cerebral Resuscitation Engineering Technology, Zhengzhou 450003, China
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Qian J, Min X, Wang F, Xu Y, Fang W. Paroxysmal Sympathetic Hyperactivity in Adult Patients with Brain Injury: A Systematic Review and Meta-Analysis. World Neurosurg 2022; 166:212-219. [PMID: 35398326 DOI: 10.1016/j.wneu.2022.03.141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 03/30/2022] [Accepted: 03/31/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Paroxysmal sympathetic hyperactivity (PSH) is a syndrome of excessive sympathetic activity, mainly occurring in severe traumatic brain injury. However, few studies have reported the frequency of PSH and its related risk factors in adult patients with brain injury. METHODS We performed this systematic review and meta-analysis to estimate the combined incidence of PSH and the associated risk factors in adult patients with brain injury. This study was registered with the PROSPERO international prospective register of systematic reviews (https://www.crd.york. ac.uk/PROSPERO/Identifier: CRD 42021260493), and a systematic search was conducted of the scientific databases Embase, PubMed, Web of Science, Cochrane Library, and Google Scholar. All identified observational studies regarding the incidence and risk factors of PSH in adult patients with brain injury were included. Two authors extracted data independently; data were analyzed by STATA version 16. RESULTS The search yielded 9 studies involving 1643 adult patients. PSH was detected in 438 patients. The combined incidence of PSH in adult patients with brain injury was 27.4% (95% confidence interval [CI], 0.190-0.358). The risk factors include patients' age (SMD = -0.592; I2 = 77.5%; 95% CI, -1.027 to -0.156; P = 0.008), traffic accident (odds ratio [OR], 1.783; I2 =18.0%; 95% CI, 1.128-2.820; P = 0.013), admission Glasgow Coma Scale score (SMD = -1.097; I2 =28.3%; 95% CI, -1.500 to -0.693; P = 0.000), hydrocephalus (OR, 3.936; I2 =67.9%; 95% CI, 1.144-13.540; P = 0.030), and diffuse axonal injury (OR, 4.747; I2 =71.1%; 95% CI, 1.221-18.463; P = 0.025) and were significantly associated with the presence of PSH after brain injury. CONCLUSIONS PSH occurs in nearly a quarter of adult patients with brain injury. Patient's age, traffic accident, admission Glasgow Coma Scale score, hydrocephalus, and diffuse axonal injury were risk factors for PSH in adult patients with brain injury. These findings may contribute to novel strategies for early diagnosis and interventions that aid in the rehabilitation of patients with brain injury.
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Affiliation(s)
- Jiawei Qian
- Department of Neurosurgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaoqiang Min
- College of Pharmaceutical Science, Zhejiang University of Technology, Hangzhou, China
| | - Feng Wang
- Department of Neurosurgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yuanhua Xu
- Department of Neurosurgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wenchao Fang
- Department of Neurosurgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
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Chen Z, Zhang Y, Wu X, Huang H, Chen W, Su Y. Characteristics and Outcomes of Paroxysmal Sympathetic Hyperactivity in Anti-NMDAR Encephalitis. Front Immunol 2022; 13:858450. [PMID: 35464412 PMCID: PMC9020260 DOI: 10.3389/fimmu.2022.858450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 03/14/2022] [Indexed: 11/18/2022] Open
Abstract
Background To explore the clinical characteristics and prognosis of autonomic dysfunction and paroxysmal sympathetic hyperactivity (PSH), and evaluate the efficacy of drugs used to suppress PSH episode in anti-NMDAR encephalitis patients. Methods Patients who met the diagnostic criteria of anti-NMDAR encephalitis were enrolled from January 2012 to August 2018 and followed up for 2 years. PSH was diagnosed according to the PSH-Assessment Measure. The demographics data, clinical features, auxiliary tests results, treatments, and outcomes were prospective collected and analyzed. Results A total of 132 anti-NMDAR encephalitis patients were enrolled, of which 27.3% and 9.1% experienced autonomic dysfunction and probable PSH respectively. Cardiac autonomic dysfunction was the most common subtype (77.8%). Patients with a higher incidence of ovarian teratoma, mechanical ventilation, neurological intensive care unit admission, and elevated glucose and NMDAR antibody titer in the CSF were more likely to exhibit autonomic dysfunction or PSH. Episodes of PSH can be suppressed by monotherapy in patients without prior sedative drug use with an efficacy of 90%. No significant difference was observed between the prognosis of patients with or without autonomic dysfunction, or between the PSH versus non-PSH groups after 6 months and even during long-term follow-up. However, patients with cardiac autonomic dysfunction had poor prognosis at 6 months. Conclusion PSH is a common clinical condition in patients with anti-NMDAR encephalitis, especially in severe cases, and can be effectively managed by several drug monotherapies. Despite necessitating longer hospital stay, autonomic dysfunction or PSH do not seem to compromise the neurological recovery of patients.
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Affiliation(s)
- Zhongyun Chen
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yan Zhang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiaowen Wu
- Department of Neurology, The Second Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Huijin Huang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Weibi Chen
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yingying Su
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
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Leveraging Continuous Vital Sign Measurements for Real-Time Assessment of Autonomic Nervous System Dysfunction After Brain Injury: A Narrative Review of Current and Future Applications. Neurocrit Care 2022; 37:206-219. [PMID: 35411542 DOI: 10.1007/s12028-022-01491-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 03/14/2022] [Indexed: 02/03/2023]
Abstract
Subtle and profound changes in autonomic nervous system (ANS) function affecting sympathetic and parasympathetic homeostasis occur as a result of critical illness. Changes in ANS function are particularly salient in neurocritical illness, when direct structural and functional perturbations to autonomic network pathways occur and may herald impending clinical deterioration or intervenable evolving mechanisms of secondary injury. Sympathetic and parasympathetic balance can be measured quantitatively at the bedside using multiple methods, most readily by extracting data from electrocardiographic or photoplethysmography waveforms. Work from our group and others has demonstrated that data-analytic techniques can identify quantitative physiologic changes that precede clinical detection of meaningful events, and therefore may provide an important window for time-sensitive therapies. Here, we review data-analytic approaches to measuring ANS dysfunction from routine bedside physiologic data streams and integrating this data into multimodal machine learning-based model development to better understand phenotypical expression of pathophysiologic mechanisms and perhaps even serve as early detection signals. Attention will be given to examples from our work in acute traumatic brain injury on detection and monitoring of paroxysmal sympathetic hyperactivity and prediction of neurologic deterioration, and in large hemispheric infarction on prediction of malignant cerebral edema. We also discuss future clinical applications and data-analytic challenges and future directions.
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Bithal PK, Chavali S. Paroxysmal Sympathetic Hyperactivity: Ignoring the Presence of an Elephant in the Room. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2021. [DOI: 10.1055/s-0041-1740206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Parmod K. Bithal
- Former Professor and Head, Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Siddharth Chavali
- Department of Neuroanaesthesia, Neurocritical Care and Pain Medicine, Asian Institute of Gastroenterology Hospitals, Hyderabad, Telangana, India
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Tu JSY, Reeve J, Deane AM, Plummer MP. Pharmacological Management of Paroxysmal Sympathetic Hyperactivity: A Scoping Review. J Neurotrauma 2021; 38:2221-2237. [PMID: 33823679 DOI: 10.1089/neu.2020.7597] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Paroxysmal sympathetic hyperactivity (PSH) occurs in ∼10% of patients following acute severe brain injury. While PSH is associated with worse outcomes, there are no clinical practice guidelines to inform treatment. We aimed to systematically review the literature on the pharmacological management of PSH. MEDLINE, Embase, and Cochrane library databases were searched from inception to August 2020. Eligible studies met the following criteria: 1) randomized controlled trials, non-randomized controlled trials (case control or controlled cohort), observational studies, case series, and case reports; 2) study population of adult and pediatric patients; 3) exposure to an acute neurological insult complicated by PSH (or historic synonym); 4) description of pharmacological treatment of PSH. Our search retrieved 2729 citations with 83 articles assessed for inclusion. After full text extraction, 56 manuscripts inclusive of 459 patients met eligibility criteria. We identified 31 case reports, 15 case series (152 patients), seven retrospective case control or cohort studies (212 patients), and three prospective observational studies (52 patients). Traumatic brain injury was the most common precipitating insult (407 patients), followed by hypoxic encephalopathy (72 patients) and intracranial hemorrhage (10 patients). There were 48 drugs from 22 classes prescribed for the management of PSH. The most frequently prescribed agents were benzodiazepines, β-blockers, opioids, α-2 agonists, and baclofen. However, route and dose of drug and subsequent outcome were inconsistently reported, such that no summary was possible. While a wide variety of drugs have been reported to treat PSH, there is a lack of even moderate-quality evidence to inform clinical decision making.
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Affiliation(s)
| | - Jake Reeve
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia
| | - Adam M Deane
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia.,Center for Integrated Critical Care, University of Melbourne, Melbourne, Australia
| | - Mark P Plummer
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia.,Center for Integrated Critical Care, University of Melbourne, Melbourne, Australia
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12
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Admission Features Associated With Paroxysmal Sympathetic Hyperactivity After Traumatic Brain Injury: A Case-Control Study. Crit Care Med 2021; 49:e989-e1000. [PMID: 34259439 DOI: 10.1097/ccm.0000000000005076] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Paroxysmal sympathetic hyperactivity occurs in a subset of critically ill traumatic brain injury patients and has been associated with worse outcomes after traumatic brain injury. The goal of this study was to identify admission risk factors for the development of paroxysmal sympathetic hyperactivity in traumatic brain injury patients. DESIGN Retrospective case-control study of age- and Glasgow Coma Scale-matched traumatic brain injury patients. SETTING Neurotrauma ICU at the R. Adams Cowley Shock Trauma Center of the University of Maryland Medical System, January 2016 to July 2018. PATIENTS Critically ill adult traumatic brain injury patients who underwent inpatient monitoring for at least 14 days were included. Cases were identified based on treatment for paroxysmal sympathetic hyperactivity with institutional first-line therapies and were confirmed by retrospective tabulation of established paroxysmal sympathetic hyperactivity diagnostic and severity criteria. Cases were matched 1:1 by age and Glasgow Coma Scale to nonparoxysmal sympathetic hyperactivity traumatic brain injury controls, yielding 77 patients in each group. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Admission characteristics independently predictive of paroxysmal sympathetic hyperactivity included male sex, higher admission systolic blood pressure, and initial CT evidence of diffuse axonal injury, intraventricular hemorrhage/subarachnoid hemorrhage, complete cisternal effacement, and absence of contusion. Paroxysmal sympathetic hyperactivity cases demonstrated significantly worse neurologic outcomes upon hospital discharge despite being matched for injury severity at admission. CONCLUSIONS Several anatomical, epidemiologic, and physiologic risk factors for clinically relevant paroxysmal sympathetic hyperactivity can be identified on ICU admission. These features help characterize paroxysmal sympathetic hyperactivity as a clinical-pathophysiologic phenotype associated with worse outcomes after traumatic brain injury.
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Wang D, Su S, Tan M, Wu Y, Wang S. Paroxysmal Sympathetic Hyperactivity in Severe Anti-N-Methyl-d-Aspartate Receptor Encephalitis: A Single Center Retrospective Observational Study. Front Immunol 2021; 12:665183. [PMID: 33912193 PMCID: PMC8072271 DOI: 10.3389/fimmu.2021.665183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 03/12/2021] [Indexed: 12/02/2022] Open
Abstract
Background Paroxysmal sympathetic hyperactivity (PSH) is a disorder with excessive sympathetic activity commonly recognized in patients with acquired brain injury. Autonomic instability is frequent in anti-N-methyl-d-aspartate receptor encephalitis (anti-NMDARE). However, PSH in anti-NMDARE has gained little attention. Methods We retrospectively reviewed 24 patients diagnosed with severe anti-NMDARE in the neuro-intensive care unit (NICU) between 2014 and 2019. Patients were assessed with the PSH assessment measure (PSH-AM) scale, and categorized into “PSH+” group and “PSH-” group. The clinical characteristics, hospital mortality, and functional outcome by modified Rankin Scale (mRS) score at six months after discharge were compared between the two groups. Among patients with PSH+, the clinical features and pharmacotherapy of PSH were summarized and compared. Results Twenty-four patients were included in the study. Twelve of them (50%) were categorized as PSH+ based on PSH-AM scores. There were no significant differences in the demographic characteristic, GCS scores upon admission, incidence of status epilepticus, teratoma occurrence, hospital mortality, and 6-month mRS between PSH+ and PSH- groups. Patients with PSH+ had increased length of NICU stay, hospital stay and duration of mechanical ventilation. The most prominent clinical features of PSH in severe anti-NMDARE were tachycardia and hyperthermia, while posturing was the relatively mildest clinical feature. Propranolol and clonazepam were more commonly used than gabapentin in pharmacotherapy of PSH in severe anti-NMDARE. Conclusions The incidence of PSH in severe anti-NMDARE patients was as high as 50%. Patients with PSH demonstrated prolonged NICU stay, hospital stay and increased duration of mechanical ventilation, while no effect on hospital mortality and functional outcome. Clinicians should be aware of the distinctive characteristics and treatment options of PSH in severe anti-NMDARE.
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Affiliation(s)
- Dongmei Wang
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shuang Su
- Department of Geriatrics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Miaoqin Tan
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yongming Wu
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shengnan Wang
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
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Heterotopic ossification in a patient with paroxysmal sympathetic hyperactivity following multiple trauma complicated with vitamin D deficiency: a case report. Surg Case Rep 2020; 6:293. [PMID: 33226506 PMCID: PMC7683749 DOI: 10.1186/s40792-020-01031-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 09/23/2020] [Indexed: 11/25/2022] Open
Abstract
Background Paroxysmal sympathetic hyperactivity (PSH) may occur in patients with traumatic brain injury. Heterotopic ossification (HO) has frequently been observed in patients with PSH and has been found to impair patients’ recoveries. However, the pathophysiology of HO in patients with PSH remains unelucidated. Vitamin D deficiency is a common abnormality among critically ill patients and may be associated not only with musculoskeletal complications, but also with high morbidity and mortality. The association between vitamin D deficiency and HO in patients with PSH has not yet been evaluated. Case presentation A 21-year-old man was in a motorcycle accident. The initial diagnosis was diffused axonal injury, thoracic aortic injury, bilateral lung contusion with hemopneumothorax, liver injury, vertebral injury of T5, along with fractures of the right humerus, left patella, bilateral scapula, and a stable pelvic fracture, with an Injury Severity Score of 50. Two weeks after admission, he was diagnosed with PSH. One month after the injury, decreased joint mobility and progressive pain were evident. Computed tomography (CT) showed HO in his humerus, ulna, radius, scapula, ilium, pubis, ischium, knee joint, patella, and tibia, as well as renal calculus. To evaluate metabolic bone abnormalities, we measured levels of 25-OH vitamin D, parathyroid hormone, calcitonin, procollagen type I N-terminal propeptide (a marker of bone formation), and tartrate-resistant acid phosphatase 5b (a marker of bone resorption). This revealed a vitamin D deficiency. Bisphosphonate agents and vitamin D were administered for 1 month. Thereafter, his symptoms, radiographic findings, and laboratory abnormalities improved, and he was transferred to another facility. Conclusions HO in patients with PSH, following severe head injury, may be associated with vitamin D deficiency. Medication for vitamin-D-related metabolism abnormalities may represent a novel intervention for HO with PSH.
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Abstract
Paroxysmal sympathetic hyperactivity (PSH) is a relatively common, but often unrecognized, complication of acute diffuse or multifocal brain diseases, most frequently encountered in young comatose patients with severe traumatic brain injury. It is presumed to be caused by loss of cortical inhibitory modulation of diencephalic and brain stem centers and possible additional maladaptive changes in the spinal cord that combine to produce exaggerated sympathetic responses to stimulation. The syndrome consists of repeated sudden episodes of tachycardia, tachypnea, hypertension, sweating, and sometimes fever and dystonic posturing. The diagnosis is clinical. Treatment includes reducing any external stimulation that can trigger the episodes, and starting abortive (e.g., intravenous morphine) and preventive medications (e.g., gabapentin, propranolol, clonidine). Prompt and adequate treatment of PSH may reduce the likelihood of secondary complications, such as dehydration, weight loss and malnutrition, and muscle contractures.
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Li Z, Chen W, Zhu Y, Han K, Wang J, Chen J, Zhang D, Yu M, Lv L, Hou L. Risk factors and clinical features of paroxysmal sympathetic hyperactivity after spontaneous intracerebral hemorrhage. Auton Neurosci 2020; 225:102643. [PMID: 32097879 DOI: 10.1016/j.autneu.2020.102643] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 01/21/2020] [Accepted: 01/24/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE Paroxysmal sympathetic hyperactivity (PSH) is a rare complication of spontaneous intracerebral hemorrhage (ICH).We aimed to evaluate the risk factors and clinical features for PSH after ICH. METHODS From January 1, 2013 to April 1, 2018, patients with ICH were consecutively included in this observational study. Baseline characteristics were compared in patients with and without PSH. Multivariate logistic regression analysis was used to determine the risk factors associated with PSH development. Clinical features of patients with PSH were also analyzed. RESULTS There were 548 patients with ICH included and a total of 15 (2.7%) patients were identified with PSH. In univariate analysis, PSH development was associated with the following: previous hemorrhagic stroke, pupils abnormity, admission Glasgow Coma Scale (GCS) score, hematoma volume, liver function abnormity, neutrophil count and early tracheostomy. Multivariate logistic regression analysis showed that a significantly increased risk of PSH was found in patients with previous hemorrhagic stroke (odds ratio [OR], 4.176; 95% confidence interval [CI], 1.111-15.698), admission GCS score (OR, 0.703; 95% CI, 0.548-0.902) and early tracheostomy (OR, 8.317; 95%CI, 1.755-39.412).The most common symptoms of PSH were hyperthermia (80%) and hyperhidrosis (80%).The median Intensive Care Unit stays and Glasgow Outcome Scale at discharge were 34 (19-46) and 2 (1.5-3), respectively. CONCLUSIONS PSH is characterized by a cluster of symptoms and abnormal vital signs, which may lead to poor outcomes in ICH. The present study suggests that previous hemorrhagic stroke, admission GCS score and early tracheostomy may be the significant risk factors for PSH after ICH.
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Affiliation(s)
- Zhenxing Li
- Department of Neurosurgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Wen Chen
- Department of Neurosurgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Yibai Zhu
- Department of Neurosurgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Kaiwei Han
- Department of Neurosurgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Junyu Wang
- Department of Neurosurgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Jigang Chen
- Department of Neurosurgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Danfeng Zhang
- Department of Neurosurgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Mingkun Yu
- Department of Neurosurgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Liquan Lv
- Department of Neurosurgery, Changzheng Hospital, Second Military Medical University, Shanghai, China.
| | - Lijun Hou
- Department of Neurosurgery, Changzheng Hospital, Second Military Medical University, Shanghai, China.
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Zheng RZ, Lei ZQ, Yang RZ, Huang GH, Zhang GM. Identification and Management of Paroxysmal Sympathetic Hyperactivity After Traumatic Brain Injury. Front Neurol 2020; 11:81. [PMID: 32161563 PMCID: PMC7052349 DOI: 10.3389/fneur.2020.00081] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 01/22/2020] [Indexed: 12/12/2022] Open
Abstract
Paroxysmal sympathetic hyperactivity (PSH) has predominantly been described after traumatic brain injury (TBI), which is associated with hyperthermia, hypertension, tachycardia, tachypnea, diaphoresis, dystonia (hypertonia or spasticity), and even motor features such as extensor/flexion posturing. Despite the pathophysiology of PSH not being completely understood, most researchers gradually agree that PSH is driven by the loss of the inhibition of excitation in the sympathetic nervous system without parasympathetic involvement. Recently, advances in the clinical and diagnostic features of PSH in TBI patients have reached a broad clinical consensus in many neurology departments. These advances should provide a more unanimous foundation for the systematic research on this clinical syndrome and its clear management. Clinically, a great deal of attention has been paid to the definition and diagnostic criteria, epidemiology and pathophysiology, symptomatic treatment, and prevention and control of secondary brain injury of PSH in TBI patients. Potential benefits of treatment for PSH may result from the three main goals: eliminating predisposing causes, mitigating excessive sympathetic outflow, and supportive therapy. However, individual pathophysiological differences, therapeutic responses and outcomes, and precision medicine approaches to PSH management are varied and inconsistent between studies. Further, many potential therapeutic drugs might suppress manifestations of PSH in the process of TBI treatment. The purpose of this review is to present current and comprehensive studies of the identification of PSH after TBI in the early stage and provide a framework for symptomatic management of TBI patients with PSH.
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Affiliation(s)
- Rui-Zhe Zheng
- Department of Anesthesiology, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhong-Qi Lei
- Department of Neurosurgery, The 901th Hospital of the Joint Logistics Support Force of PLA, Anhui, China
| | - Run-Ze Yang
- Department of Clinic of Spine Center, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Guo-Hui Huang
- Department of Otolaryngology-Head and Neck Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Guang-Ming Zhang
- Department of Anesthesiology, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Shakeri A, Zirak MR, Wallace Hayes A, Reiter R, Karimi G. Curcumin and its analogues protect from endoplasmic reticulum stress: Mechanisms and pathways. Pharmacol Res 2019; 146:104335. [DOI: 10.1016/j.phrs.2019.104335] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 06/27/2019] [Accepted: 06/28/2019] [Indexed: 02/07/2023]
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