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Ostergaard JR. Treatment of non-epileptic episodes of anxious, fearful behavior in adolescent juvenile neuronal ceroid lipofuscinosis (CLN3 disease). Front Neurol 2023; 14:1216861. [PMID: 37771451 PMCID: PMC10523314 DOI: 10.3389/fneur.2023.1216861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 08/28/2023] [Indexed: 09/30/2023] Open
Abstract
Background Recurrent non-epileptic episodes of frightened facial and body expression occur in more than half of post-adolescent patients with juvenile neuronal ceroid lipofuscinosis (JNCL, CLN3 disease). Clinically, the episodes look similar to the attacks of paroxysmal sympathetic hyperactivity (PSH) commonly seen following traumatic brain injury (TBI). The episodes occur when the patients are exposed to separation, hear loud sounds or are otherwise bothered by discomfort and as in PSH following TBI, the attacks are difficult to prevent and/or treat. Aim and methods Based on present knowledge of triggering factors, the neural anxiety/fear circuit, its afferent and efferent pathways and documented CLN3 disease-impact on these tracks, the current study discusses a rational approach how to prevent and/or treat the attacks. Results Patients with JNCL have a disturbed somatosensory modulation leading to a reduced threshold of pain; a degeneration within the neural anxiety/fear circuit leading to an imbalance of central network inhibition and excitation pathways; and finally, an, with advancing age, increasing autonomic imbalance leading to a significant dominance of the sympathetic neural system. Discussion Theoretically, there are three points of attack how to prevent or treat the episodes: (1) increase in threshold of discomfort impact; (2) modulation of imbalance of central network inhibition and excitation, and (3) restoring the balance between the sympathetic and parasympathetic neural systems prompted by a parasympathetic withdrawal. As to (1) and (2), prevention should have the greatest priority. As regards (3), research of transcutaneous vagal stimulation treatment in JNCL is warranted.
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Affiliation(s)
- John R. Ostergaard
- Department of Child and Adolescence, Centre for Rare Diseases, Aarhus University Hospital, Aarhus, Denmark
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Cocuzzo B, Fisher KA, Alvarez Villalba CL. Neuroleptic Malignant Syndrome Status Post Anoxic Brain Injury: A Case Presentation of Heightened Susceptibility in the Brain Injury Population. Cureus 2023; 15:e35740. [PMID: 37025743 PMCID: PMC10072192 DOI: 10.7759/cureus.35740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2023] [Indexed: 03/06/2023] Open
Abstract
Neuroleptic malignant syndrome (NMS), a potentially life-threatening neurological emergency characterized by muscle rigidity, altered mental status (AMS), autonomic instability, and hyperthermia, is most commonly precipitated by high-potency first-generation antipsychotics due to central dopamine receptor blockade. There is a heightened risk of NMS in animals with ischemic brain injury (IBI) or traumatic brain injury (TBI) due to the resulting death of dopaminergic neurons from injury and the dopamine receptor blockade elicited upon recovery. To the best of our knowledge, this will be the first documented case of a critically ill patient, with a history of prior exposure to antipsychotics, who suffered an anoxic brain injury with subsequent development of NMS after the initiation of haloperidol for the treatment of acute agitation. Further investigation is necessary to expand upon the existing literature suggesting the role of alternative agents, including amantadine, due to its impact on dopaminergic transmission, as well as dopamine and glutamine release. Furthermore, NMS can be difficult to diagnose due to variable clinical presentation and lack of absolute diagnostic criteria, which is further compounded with central nervous system (CNS) injury, where neurological abnormalities and AMS may be attributed to the injury, rather than a medication effect, especially in the early period. This case highlights the significance of prompt recognition with appropriate treatment of NMS in vulnerable and susceptible patients suffering from brain injury.
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Ostergaard JR. Etiology of anxious and fearful behavior in juvenile neuronal ceroid lipofuscinosis (CLN3 disease). Front Psychiatry 2023; 14:1059082. [PMID: 37113550 PMCID: PMC10126397 DOI: 10.3389/fpsyt.2023.1059082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 03/27/2023] [Indexed: 04/29/2023] Open
Abstract
Background Juvenile neuronal ceroid lipofuscinosis (JNCL, CLN3) is a childhood-onset neurodegenerative disease with prominent symptoms comprising a pediatric dementia syndrome. As in adult dementia, behavioral symptoms like mood disturbances and anxiety are common. In contrast to in adult dementia, however, the anxious behavioral symptoms increase during the terminal phase of JNCL disease. In the present study, the current understanding of the neurobiological mechanisms of anxiety and anxious behavior in general is addressed as will a discussion of the mechanism of the anxious behavior seen in young JNCL patients. Based on developmental behavioral points of view, known neurobiological mechanisms, and the clinical presentation of the anxious behavior, a theory of its etiology is described. Result and discussion During the terminal phase, the cognitive developmental age of JNCL patients is below 2 years. At this stage of mental development individuals act primarily from a concrete world of consciousness and do not have the cognitive ability to encounter a normal anxiety response. Instead, they experience the evolutionary basic emotion of fear, and as the episodes typically are provoked when the adolescent JNCL patient is exposed to either loud sounds, is lifted from the ground, or separated from the mother/known caregiver, the fear can best be perceived as the developmental natural fear-response that appears in children 0-2 years of age. The efferent pathways of the neural fear circuits are mediated through autonomic, neuroendocrine, and skeletal-motor responses. The autonomic activation occurs early, is mediated through the sympathetic and parasympathetic neural systems, and as JNCL patients beyond puberty have an autonomic imbalance with a significant sympathetic hyperactivity, the activation of the autonomic nervous system results in a disproportionate high sympathetic activity resulting in tachycardia, tachypnea, excessive sweating, hyperthermia, and an increased atypical muscle activity. The episodes are thus phenotypically similar to what is seen as Paroxysmal Sympathetic Hyperactivity (PSH) following an acute traumatic brain injury. As in PSH, treatment is difficult and so far, no consensus of a treatment algorithm exists. Use of sedative and analgesic medication and minimizing or avoiding provocative stimuli may partly reduce the frequency and intensity of the attacks. Transcutaneous vagal nerve stimulation might be an option worth to investigate rebalancing the sympathetic-parasympathetic disproportion.
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Abstract
PURPOSE OF REVIEW Autonomic hyperactivity is a relatively common consequence of severe acute brain injury and can also be seen with spinal cord and peripheral nerve disorders. This article reviews basic pathophysiologic concepts regarding autonomic hyperactivity, its various forms of clinical presentation, and practical management considerations. RECENT FINDINGS Paroxysmal sympathetic hyperactivity is most common after traumatic brain injury but can also occur after other forms of severe acute diffuse or multifocal brain injury. Formal criteria for the diagnosis and severity grading of paroxysmal sympathetic hyperactivity have now been proposed. A growing body of literature is beginning to elucidate the mechanisms underlying this disorder, but treatment remains based on observational data. Our mechanistic understanding of other distinct forms of autonomic hyperactivity, such as autonomic dysreflexia after traumatic spinal cord injury and dysautonomia after Guillain-Barré syndrome, remains rudimentary, yet clinical experience shows that their appropriate management can minimize the risk of serious complications. SUMMARY Syndromes of autonomic hyperactivity can result from injury at all levels of the neuraxis. Much more research is needed to refine our understanding of these disorders and guide optimal management decisions.
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Nash RP, Weinberg MS, Laughon SL, McCall RC, Bateman JR, Rosenstein DL. Acute Pharmacological Management of Behavioral and Emotional Dysregulation Following a Traumatic Brain Injury: A Systematic Review of the Literature. PSYCHOSOMATICS 2019; 60:139-152. [DOI: 10.1016/j.psym.2018.11.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 11/29/2018] [Accepted: 11/30/2018] [Indexed: 10/27/2022]
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Cheng JP, Leary JB, O'Neil DA, Meyer EA, Free KE, Bondi CO, Kline AE. Spontaneous recovery of traumatic brain injury-induced functional deficits is not hindered by daily administration of lorazepam. Behav Brain Res 2017; 339:215-221. [PMID: 29203336 DOI: 10.1016/j.bbr.2017.11.039] [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: 08/29/2017] [Revised: 11/02/2017] [Accepted: 11/30/2017] [Indexed: 10/18/2022]
Abstract
Agitation and aggression are common sequelae of traumatic brain injury (TBI) and pose a challenge to physicians and other health providers during acute patient care and subsequent neurorehabilitation. Antipsychotic drugs (APDs) are routinely administered to manage TBI patients displaying such maladaptive behaviors despite several clinical and preclinical studies demonstrating that they hinder recovery. A potentially viable alternative to APDs may be the benzodiazepines, which have differing mechanisms of action. Hence, the aim of the study was to test the hypothesis that lorazepam (LOR) would not impede recovery after TBI. Anesthetized adult male rats received a cortical impact or sham injury and then were intraperitoneally administered LOR (0.1mg/kg, 1.0mg/kg, or 2.0mg/kg) or vehicle (VEH; 1mL/kg) commencing 24-h after surgery and once daily for 19days. Motor and cognitive outcomes were assessed on post-operative days 1-5 and 14-19, respectively. No differences were revealed among the four sham control groups and thus they were pooled into one inclusive SHAM group. The SHAMs performed better than all TBI groups on all assessments (p<0.05). Regarding TBI, the 2.0mg/kg LOR group performed better than the VEH and 0.1mg/kg or 1.0mg/kg LOR groups on every task (p<0.05); no differences were observed among the latter three groups on any endpoint (p>0.05). Overall, these preclinical behavioral data support the hypothesis and reveal a therapeutic benefit with the higher dose of LOR. The findings suggest that LOR may be an alternative, to APDs, for controlling agitation without compromising spontaneous recovery and perhaps could afford a dual benefit by also promoting therapeutic efficacy.
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Affiliation(s)
- Jeffrey P Cheng
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA, 15213, United States; Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, 15213, United States
| | - Jacob B Leary
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA, 15213, United States; Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, 15213, United States
| | - Darik A O'Neil
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA, 15213, United States; Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, 15213, United States
| | - Elizabeth A Meyer
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA, 15213, United States; Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, 15213, United States
| | - Kristin E Free
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA, 15213, United States; Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, 15213, United States
| | - Corina O Bondi
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA, 15213, United States; Neurobiology, University of Pittsburgh, Pittsburgh, PA, 15213, United States; Center for Neuroscience, University of Pittsburgh, Pittsburgh, PA, 15213, United States
| | - Anthony E Kline
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA, 15213, United States; Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, 15213, United States; Center for Neuroscience, University of Pittsburgh, Pittsburgh, PA, 15213, United States; Center for the Neural Basis of Cognition, University of Pittsburgh, Pittsburgh, PA, 15213, United States; Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, 15213, United States; Psychology, University of Pittsburgh, PA, 15213, United States.
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Yue JK, Rick JW, Deng H, Feldman MJ, Winkler EA. Efficacy of decompressive craniectomy in the management of intracranial pressure in severe traumatic brain injury. J Neurosurg Sci 2017; 63:425-440. [PMID: 29115100 DOI: 10.23736/s0390-5616.17.04133-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Traumatic brain injury (TBI) is a common cause of permanent disability for which clinical management remains suboptimal. Elevated intracranial pressure (ICP) is a common sequela following TBI leading to death and permanent disability if not properly managed. While clinicians often employ stepwise acute care algorithms to reduce ICP, a number of patients will fail medical management and may be considered for surgical decompression. Decompressive craniectomy (DC) involves removing a component of the bony skull to allow cerebral tissue expansion in order to reduce ICP. However, the impact of DC, which is performed in the setting of neurological instability, ongoing secondary injury, and patient resuscitation, has been challenging to study and outcomes are not well understood. This review summarizes historical and recent studies to elucidate indications for DC and the nuances, risks and complications in its application. The pathophysiology driving ICP elevation, and the corresponding medical interventions for their temporization and treatment, are thoroughly described. The current state of DC - including appropriate injury classification, surgical techniques, concurrent medical therapies, mortality and functional outcomes - is presented. We also report on the recent updates from large randomized controlled trials in severe TBI (Decompressive Craniectomy [DECRA] and Randomized Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of ICP [RESCUEicp]), and recommendations for early DC to treat refractory ICP elevations in malignant middle cerebral artery syndrome. Limitations for DC, such as the equipoise between immediate reduction in ICP and clinically meaningful functional outcomes, are discussed in support of future investigations.
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Affiliation(s)
- John K Yue
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Jonathan W Rick
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Hansen Deng
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Michael J Feldman
- Department of Neurological Surgery, Vanderbilt University, Nashville, TN, USA
| | - Ethan A Winkler
- Department of Neurological Surgery, University of California, San Francisco, CA, USA -
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Abstract
Objective: To review evidence for the treatment of neuroleptic malignant syndrome (NMS) and to discuss how to rechallenge patients with neuroleptics when continued pharmacotherapy for chronic psychological illness is required. Data Sources: A PubMed search was conducted through March 2016 using available medical subject heading (MeSH) terms and keywords that included neuroleptic malignant syndrome, treatment, dantrolene, and bromocriptine. A manual search of article reference sections followed. Study Selection and Data Extraction: Case reports and case series in English that discussed NMS and atypical NMS treatment as well as neuroleptic rechallenge were included for review. Data Synthesis: The reported incidence of NMS was 0.02% to 0.03%, with a mortality rate of 5.6%. Current literature on NMS is primarily retrospective and emphasizes diagnostic criteria, causative agents, and potential pharmacotherapy. Details regarding timing of administration, dose, and duration of pharmacotherapy are inconsistently reported. Reported dosing strategies and outcomes have been summarized. Instances of rechallenge were infrequently reported but demonstrate that recurrence may happen at any time after NMS resolution. Recommendations regarding safe rechallenge are provided. Conclusion: NMS is a rare adverse drug reaction, with a complex pathophysiology and presentation. Timely diagnosis and discontinuation of antipsychotic therapy is the first-line treatment, followed by supportive care and pharmacotherapy. Antipsychotic rechallenge is often required and should be attempted only after a drug-free period and with a different agent, slowly titrated with close monitoring.
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Affiliation(s)
| | - Aaron M. Cook
- University of Kentucky Chandler Medical Center, Lexington, KY, USA
- University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science, Lexington, KY, USA
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Plantier D, Luauté J. Drugs for behavior disorders after traumatic brain injury: Systematic review and expert consensus leading to French recommendations for good practice. Ann Phys Rehabil Med 2016; 59:42-57. [PMID: 26797170 DOI: 10.1016/j.rehab.2015.10.003] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 10/12/2015] [Accepted: 10/18/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE There are no handbook or recommendations for the use of pharmacological agents to treat neurobehavioral disorders after traumatic brain injury (TBI). This work proposes a systematic review of the literature and a user guide on neuroleptics, antidepressants, beta-blockers, mood stabilizers and other medications for irritability, aggressiveness, agitation, impulsivity, depression, apathy… METHOD Steering, working and reading groups (62 people) were formed under the control of the French High Authority for Health (HAS) in collaboration with the SOFMER scientific society (French Society of Physical and Rehabilitation Medicine). Articles were searched by HAS officers in the Medline database from 1990 to 2012, crossing TBI and pharmacological agents. The HAS method to select, read and analyze papers is close to the PRISMA statements. RESULTS Out of 772 references, 89 were analyzed, covering a total of 1306 people with TBI. There is insufficient evidence to standardize drug treatments for these disorders. There are however some elements to establish consensus recommendations for good clinical practice. Propranolol can improve aggression (B grade). Carbamazepine and valproate seem effective on agitation and aggression and are recommended as first line treatment (Expert Consensus [EC]). There is no evidence of efficacy for neuroleptics. Their prescription is based on emergency situation for a crisis (loxapine) but not for long-term use (EC). Antidepressants are recommended to treat depression (EC) with a higher standard of proof for Selective Serotonin Reuptake Inhibitors (SSRI, grade B). Other products are described. CONCLUSION The choice of treatment depends on the level of evidence, target symptoms, custom objectives, clinical experience and caution strategies.
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Affiliation(s)
- D Plantier
- Department of Physical Medicine and Rehabilitation (PM&R), Neurological Rehabilitation, Renée-Sabran Hospital, University Hospital of Lyon, boulevard Édouard-Herriot, 83400 Hyères, France.
| | - J Luauté
- Physical Medicine and Rehabilitation, Neurological Rehabilitation, Henry-Gabrielle Hospital, University Hospital of Lyon, 69230 Saint-Genis-Laval, France; Neuroscience Research Center of Lyon (CRNL) IMPACT team, Inserm U1028, CNRS, UMR5292, 69500 Bron, France
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Park HJ, Kim JY. Incidence of Neutropenia With Valproate and Quetiapine Combination Treatment in Subjects With Acquired Brain Injuries. Arch Phys Med Rehabil 2015; 97:183-8. [PMID: 26427579 DOI: 10.1016/j.apmr.2015.09.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 09/01/2015] [Accepted: 09/10/2015] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To investigate whether the incidence of neutropenia was higher in subjects who received a combination treatment with valproate and quetiapine than in those who were administered monotherapy. DESIGN Retrospective cohort study. SETTING Rehabilitation department of a university hospital. PARTICIPANTS Patients with acquired brain injuries who had taken valproate for seizures or quetiapine for delirium for >7 days (N=101). Data were extracted from electronic medical records of the hospital. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Incidence of neutropenia (absolute neutrophil count<2000 cells/μL) was elicited from the weekly complete blood cell records for 71.07±43.71 days of observation. The odds ratio for neutropenia development was calculated and adjusted for variables that showed significant differences between patients with or without neutropenia. RESULTS The incidence of neutropenia was significantly higher in the group receiving the combination treatment than in those receiving the monotherapy (32.26% vs 12.90%, adjusted P=.036), despite a lack of any differences in the daily doses of the medications. Coadministration of quetiapine and valproate was the predictor of neutropenia development when age, body weight, and underlying diseases were adjusted in the logistic regression model (odds ratio=3.749; 95% confidence interval, 1.161-12.099; P=.027). CONCLUSIONS Administration of quetiapine together with valproate in patients with acquired brain injury could increase the incidence of medication-induced neutropenia.
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Affiliation(s)
- Hee Jung Park
- Department of Rehabilitation Medicine, Dankook University College of Medicine, Cheonan, South Korea
| | - Jung Yoon Kim
- Ewha Brain Institute, Ewha Womans University, Seoul, South Korea.
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Feng Y, Zheng X, Fang Z. Treatment Progress of Paroxysmal Sympathetic Hyperactivity after Acquired Brain Injury. Pediatr Neurosurg 2015; 50:301-9. [PMID: 26352612 DOI: 10.1159/000439282] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 08/09/2015] [Indexed: 11/19/2022]
Abstract
Paroxysmal sympathetic hyperactivity (PSH) is a common complication of various acquired brain injuries such as traumatic brain injury, subarachnoid hemorrhage, anoxic brain injury, intracerebral hemorrhage, and others. It is manifested by tachycardia, hypertension, tachypnea, diaphoresis, and dystonic posturing. The development of PSH can prolong hospitalization and lead to secondary brain injury and even death. Despite the awareness of the serious clinical impact, there is no consensus on diagnostic criteria. Thus, misdiagnosis and delayed recognition is very common. Most of the current treatment programs come from case reports and small case series; there are very few large-scale randomized controlled trials. Generally accepted medications are opioids, β-blockers and gabapentin (usually used in combination). However, the efficacy of these drugs has not been systematically assessed. The purpose of this review is to determine the treatment strategies and drugs commonly used for PSH at the overall level.
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Detweiler MB, Sullivan K, Sharma TR, Kim KY, Detweiler JG. Case reports of neuroleptic malignant syndrome in context of quetiapine use. Psychiatr Q 2013; 84:523-41. [PMID: 23686527 DOI: 10.1007/s11126-013-9264-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
A retrospective analysis was followed on 20 case reports covering the possible correlation between the atypical antipsychotic, quetiapine, and neuroleptic malignant syndrome (NMS), determined by the study of 7 different NMS criteria guidelines. A great majority (19) of the case studies did not meet the requirements of all 7 guidelines, frequently due to unreported information. Nor was quetiapine proven to be the sole cause of the possible NMS in the two age groups investigated. Only one case was found to have no other medication or medical conditions confounding the relationship of quetiapine and NMS symptoms, and that case was in the context of a significant quetiapine overdose. The other 19 cases demonstrated the difficulty of identifying the cause of NMS when polypharmacy and other medical conditions are involved. The authors note the need for caution in deciding both the presence of NMS and the causal factors of the symptoms.
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Affiliation(s)
- Mark B Detweiler
- Psychiatry Service, Veterans Affairs Medical Center, 1970 Roanoke Boulevard (116A7), Salem, VA, 24153, USA,
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Dixit D, Shrestha P, Adelman M. Neuroleptic malignant syndrome associated with haloperidol use in critical care setting: should haloperidol still be considered the drug of choice for the management of delirium in the critical care setting? BMJ Case Rep 2013; 2013:bcr-2013-010133. [PMID: 23853022 DOI: 10.1136/bcr-2013-010133] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 48-year-old man was brought to the emergency department because of intoxication. The patient was in respiratory distress, subsequently intubated for airway protection. On hospital day 5, he was diagnosed with delirium. Haloperidol was initiated at 5 mg intravenous every 6 h and titrated up to a dose of 60 mg /day over 5 days. On hospital day 18, his temperature peaked to 107.1°F. Other symptoms included mental status change, muscular rigidity and autonomic dysfunction. Neuroleptic malignant syndrome (NMS) associated with haloperidol was suspected. No other causes for these symptoms were present. Concurrent medications were reviewed and ruled out for possible drug-induced fever. Haloperidol was discontinued and dantrolene and bromocriptine was initiated. The temperature decreased to 102.2°F within 3 h and other symptoms resolved overtime. The temporal relationship between the patient's fever decline with the discontinuation of haloperidol, and improvement with dantrolene and bromocriptine, the diagnosis was believed to be haloperidol-induced NMS.
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Affiliation(s)
- Deepali Dixit
- Department of Pharmacy, Rutgers University, Piscataway, New Jersey, USA.
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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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Neuroleptic malignant syndrome associated with haloperidol treatment in a patient with head injury. FORMOSAN JOURNAL OF SURGERY 2013. [DOI: 10.1016/j.fjs.2013.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Plantier D, Luauté J, Richard I. Prise en charge pharmacologique des troubles neurocomportementaux après traumatisme crânien : revue bibliographique, données pratiques actuelles. ACTA ACUST UNITED AC 2012. [DOI: 10.3917/inpsy.8805.0375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Shaikh N, Al-Sulaiti G, Nasser A, Rahman MA. Neuroleptic malignant syndrome and closed head injury: A case report and review. Asian J Neurosurg 2011; 6:101-5. [PMID: 22347333 PMCID: PMC3277062 DOI: 10.4103/1793-5482.92173] [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] [Indexed: 11/04/2022] Open
Abstract
Neuroleptic malignant syndrome (NMS) is a rare, but potentially lethal neurological emergency. Fifty percent of traumatic brain injury (TBI) patients will have emotional disorders and post-traumatic agitations. Haloperidol is a neuroleptic antipsychotic medication commonly used in the traumatic brain injury patients due to its advantage of no effect on respiration and conscious level. But it is one of the common medications causing NMS. A 19-year-old male driver involved in the road traffic accident had an acute subdural hematoma, which was immediately evacuated. Postoperatively, he was awake. He was weaned from ventilator and extubated. He received 20 mg of intravenous haloperidol in divided doses with in 24 hours to control his agitation. Next day, he became drowsy, spastic, febrile, and tachycardic with labile blood pressure. He was diagnosed to have NMS, needed intubation, aggressive hydration and pharmacological treatment with dentrolene sodium and bromocriptin. He was weaned from ventilator and extubated on day 17. He was transferred to the ward and then discharged to be followed in out-patient clinic. NMS in head injury patient is rare and difficult to diagnose. Diagnosis of NMS should be suspected if two of the four cardinal signs and symptoms are developed following the use of neuroleptic or dopamine agonist medication withdrawal.
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Affiliation(s)
- Nissar Shaikh
- Department of Anesthesia/ICU, Hamad Medical Corporation, Doha-Qatar
| | | | - Abdel Nasser
- Department of Neurosurgery, Hamad Medical Corporation, Doha-Qatar
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Pangilinan PH, Giacoletti-Argento A, Shellhaas R, Hurvitz EA, Hornyak JE. Neuropharmacology in Pediatric Brain Injury: A Review. PM R 2010; 2:1127-40. [DOI: 10.1016/j.pmrj.2010.07.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Revised: 06/16/2010] [Accepted: 07/05/2010] [Indexed: 11/28/2022]
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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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Neuroleptic malignant syndrome in traumatic brain injury patients treated with haloperidol. ACTA ACUST UNITED AC 2009; 66:954-8. [PMID: 19276778 DOI: 10.1097/ta.0b013e31818e90ed] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Haloperidol, which is commonly used to treat agitation in critically ill patients, has been associated with the development of neuroleptic malignant syndrome (NMS). The purpose of this manuscript was to review the literature describing NMS and haloperidol use in patients sustaining a traumatic brain injury (TBI) since these patients may be at greater risk for NMS. METHODS A computerized search of MEDLINE was conducted (1966-May 2008) to identify all publications in which haloperidol was related to NMS in patients with a TBI. The references of these manuscripts were reviewed for additional literature. RESULTS Nine case reports describe the development of NMS in patients with TBI treated with haloperidol for agitation. Cumulative haloperidol doses before the onset of NMS ranged from 10 mg to at least 210 mg. Most of these patients received high dose (> or =30 mg) haloperidol. Four patients received haloperidol parenterally. On diagnosis, of NMS, haloperidol was discontinued in five cases, and all were given supportive care and pharmacologic treatment. Patients were discharged with improved, but diminished functional capacity. CONCLUSION Development of NMS in TBI patients treated with haloperidol should be a concern for clinicians since these patients may be at greater risk for this adverse event; especially if the patient is receiving haloperidol at high doses parenterally. Future studies are needed to evaluate the incidence and increased risk of adverse events in patients sustaining a TBI and receiving haloperidol especially since haloperidol is being used more frequently in the critically ill patients.
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Rabinstein AA, Benarroch EE. Treatment of paroxysmal sympathetic hyperactivity. Curr Treat Options Neurol 2008; 10:151-7. [DOI: 10.1007/s11940-008-0016-y] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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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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Abstract
Posttraumatic agitation is a challenging problem for acute and rehabilitation staff, persons with traumatic brain injury, and their families. Specific variables for evaluation and care remain elusive. Clinical trials have not yielded a strong foundation for evidence-based practice in this arena. This review seeks to evaluate the present literature (with a focus on the decade 1995-2005) and employ previous clinical experience to deliver a review of the topic. We will discuss definitions, pathophysiology, evaluation techniques, and treatment regimens. A recommended approach to the evaluation and treatment of the person with posttraumatic agitation will be presented. The authors hope that this review will spur discussion and assist in facilitating clinical care paradigms and research programs.
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Affiliation(s)
- Lisa A Lombard
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA
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Beers SR, Skold A, Dixon CE, Adelson PD. Neurobehavioral Effects of Amantadine After Pediatric Traumatic Brain Injury. J Head Trauma Rehabil 2005; 20:450-63. [PMID: 16170253 DOI: 10.1097/00001199-200509000-00006] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate the safety and efficacy of a dopamine agonist, amantadine hydrochloride (AMH), in the treatment of neurobehavioral sequelae of pediatric TBI. PROCEDURES Age- and severity-matched traumatic brain injury groups, randomized to AMH (n = 17) or usual care (n = 10), completed behavior scales and neuropsychological tests. Effect sizes measured the treatment effect within subjects and between groups. Side effects were tracked over the 12-week study course. RESULTS Behavior improved in the AMH group, but only those 2 years or fewer postinjury showed a treatment effect on cognitive tests. CONCLUSIONS After traumatic brain injury, a 12-week course of AMH was safe and, according to parent report, improved behavior. AMH may have the potential to improve cognition in more recently injured children.
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Affiliation(s)
- Sue R Beers
- Traumatic Brain Injury Program, Western Psychiatric Institute and Clinic, Pittsburgh, PA 15213, USA.
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Richardson JD, Cocanour CS, Kern JA, Garrison RN, Kirton OC, Cofer JB, Spain DA, Thomason MH. Perioperative risk assessment in elderly and high-risk patients. J Am Coll Surg 2004; 199:133-46. [PMID: 15217641 DOI: 10.1016/j.jamcollsurg.2004.02.023] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2002] [Revised: 02/20/2004] [Accepted: 02/24/2004] [Indexed: 12/20/2022]
Affiliation(s)
- J David Richardson
- Department of Surgery, University of Louisville School of Medicine, Louisville, KY 40292, USA
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Harmsen M, Geurts ACH, Fasotti L, Bevaart BJW. Positive behavioural disturbances in the rehabilitation phase after severe traumatic brain injury: an historic cohort study. Brain Inj 2004; 18:787-96. [PMID: 15204319 DOI: 10.1080/02699050410001671757] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PRIMARY OBJECTIVE To investigate the association of post-traumatic amnesia (PTA) with positive behavioural disturbances (PBD) in an historic cohort of patients with severe traumatic brain injury (TBI) and to evaluate the use and effects of neuroleptic drugs in this cohort. RESEARCH DESIGN Historic cohort study. METHODS The medical files of 60 patients with severe TBI, selected for inpatient rehabilitation during a period of 5.5 years, were independently examined for the presence of PTA and PBD at admission in the rehabilitation centre as well as for the concomitant use of neuroleptic drugs. All TBI patients with PBD at admission were subjected to special nursing measures consisting of a structured and safe environment, a minimum number of caregivers and provision of simple and consistent feedback. As a basic policy, the use of neuroleptic medication was minimized or stopped. RESULTS Of the 28 patients suffering from PTA at admission, 16 demonstrated PBD (positive predictive value 0.57 (95% CI 0.45-0.70)). In contrast, all the 32 patients without PTA but one did not show PBD (negative predictive value 0.97 (95% CI 0.93-1.00)). Seven of the 17 patients with PBD (41%) had been prescribed neuroleptic medication, of whom five patients (81%) experienced undesired side effects. Because of the special nursing measures, these drugs could be stopped or substituted by non-neuroleptic behaviour-modifying drugs in all patients within 3 weeks, without aggravation of their PBD. CONCLUSIONS These results suggest that impaired attention and memory may play a critical role in the development of PBD in patients with severe TBI. From this perspective, maximum effort must be made to improve TBI patients' level of attention, memory and orientation instead of using mechanical or chemical restraints.
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Affiliation(s)
- M Harmsen
- Department of Rehabilitation Medicine, St. Maartenskliniek, Nijmegen, The Netherlands
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Wilson MS, Gibson CJ, Hamm RJ. Haloperidol, but Not Olanzapine, Impairs Cognitive Performance After Traumatic Brain Injury in Rats. Am J Phys Med Rehabil 2003; 82:871-9. [PMID: 14566156 DOI: 10.1097/01.phm.0000091982.33232.cb] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Traumatic brain injury can cause a variety of impairments, including persistent alterations in personality, mood, and cognition. Antipsychotic agents are frequently used to treat pathologic behaviors in traumatic brain injury patients, but the influence of prolonged administration of such drugs on cognition after injury is unknown. The effects of two antipsychotic drugs on cognitive recovery after traumatic brain injury were assessed using the fluid percussion model in rats. DESIGN The typical antipsychotic, haloperidol, and the third-generation antipsychotic, olanzapine, were administered via intraperitoneal injection beginning 24 hr after injury and continuing daily for the duration of the study. Morris water maze performance was assessed on days 11-15 postinjury. RESULTS Haloperidol, an antagonist acting on D2-like dopamine receptors, exacerbated the cognitive deficits induced by injury, as injured rats treated with 0.30 mg/kg haloperidol performed worse in the Morris water maze than injured rats treated with vehicle. CONCLUSIONS Our results demonstrate the importance of the D2 receptor in cognitive recovery after traumatic brain injury. Also, the data illustrate that some classes of antipsychotic drugs may influence cognitive recovery, and further research is needed to determine the optimal pharmacologic treatment of aggression, agitation, and other pathologic behaviors in patients with traumatic brain injury.
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Affiliation(s)
- Margaret S Wilson
- Department of Psychology, Virginia Commonwealth University, Richmond, USA
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Kadyan V, Colachis SC, Depalma MJ, Sanderson JD, Mysiw WJ. Early recognition of neuroleptic malignant syndrome during traumatic brain injury rehabilitation. Brain Inj 2003; 17:631-7. [PMID: 12775273 DOI: 10.1080/0269905031000070224] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Neuroleptic malignant syndrome is a rare disorder that manifests with hyperthermia, muscle rigidity and autonomic instability. Presented is a case series of individuals with traumatic brain injury and agitation who, when treated with neuroleptics, developed neuroleptic malignant syndrome. Although the incidence of this syndrome is rare, it is associated with significant morbidity and mortality. The onset of symptoms inconsistent with the patient's current level of recovery should alert the clinician to consider other possible diagnosis and failure to distinguish the features of neuroleptic malignant syndrome from post-traumatic agitation will delay appropriate intervention for this potentially life-threatening disorder.
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Affiliation(s)
- Vivek Kadyan
- Department of Physical Medicine and Rehabilitation, The Ohio State University Medical Center, Columbus, OH, USA.
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Abstract
OBJECTIVE To evaluate the efficacy of cyproheptadine in the management of acute intrathecal baclofen (ITB) withdrawal. DESIGN Descriptive case series. SETTING University hospital with a comprehensive in- and outpatient rehabilitation center. PARTICIPANTS Four patients (3 with spinal cord injury, 1 with cerebral palsy) with implanted ITB infusion pumps for treatment of severe spasticity, who had ITB withdrawal syndrome because of interruption of ITB infusion. INTERVENTIONS Patients were treated with 4 to 8mg of cyproheptadine by mouth every 6 to 8 hours, 5 to 10mg of diazepam by mouth every 6 to 12 hours, 10 to 20mg of baclofen by mouth every 6 hours, and ITB boluses in some cases. MAIN OUTCOME MEASURES Clinical signs and symptoms of ITB withdrawal of varying severity were assessed by vital signs (temperature, heart rate), physical examination (reflexes, tone, clonus), and patient report of symptoms (itching, nausea, headache, malaise). RESULTS The patients in our series improved significantly when the serotonin antagonist cyproheptadine was added to their regimens. Fever dropped at least 1.5 degrees C, and heart rate dropped from rates of 120 to 140 to less than 100bpm. Reflexes, tone, and myoclonus also decreased. Patients reported dramatic reduction in itching after cyproheptadine. These changes were associated temporally with cyproheptadine dosing. DISCUSSION Acute ITB withdrawal syndrome occurs frequently in cases of malfunctioning intrathecal infusion pumps or catheters. The syndrome commonly presents with pruritus and increased muscle tone. It can progress rapidly to high fever, altered mental status, seizures, profound muscle rigidity, rhabdomyolysis, brain injury, and death. Current therapy with oral baclofen and benzodiazepines is useful but has variable success, particularly in severe cases. We note that ITB withdrawal is similar to serotonergic syndromes, such as in overdoses of selective serotonin reuptake inhibitors or the popular drug of abuse 3,4-methylenedioxymethamphetamine (Ecstasy). We postulate that ITB withdrawal may be a form of serotonergic syndrome that occurs from loss of gamma-aminobutyric acid B receptor-mediated presynaptic inhibition of serotonin. CONCLUSION Cyproheptadine may be a useful adjunct to baclofen and benzodiazepines in the management of acute ITB withdrawal syndrome.
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Affiliation(s)
- Jay M Meythaler
- Department of Physical Medicine & Rehabilitation, University of Alabama School of Medicine and the University of Alabama Spain Rehabilitation Center, Birmingham 35249-7330, USA.
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Meythaler JM, Brunner RC, Johnson A, Novack TA. Amantadine to improve neurorecovery in traumatic brain injury-associated diffuse axonal injury: a pilot double-blind randomized trial. J Head Trauma Rehabil 2002; 17:300-13. [PMID: 12105999 DOI: 10.1097/00001199-200208000-00004] [Citation(s) in RCA: 193] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) caused by a high-speed transportation accident results in a mechanism of injury commonly described as diffuse axonal injury (DAI), which is associated with a reduction in dopamine turnover in the brain. Because of its affect on both dopamine and N-methyl-D-aspartate (NMDA) channels, amantadine has been the subject of considerable interest and clinical use in acute TBI. PARTICIPANTS In this study, 35 subjects, who had a TBI in a transportation accident and were initially seen with a Glasgow Coma Scale score of 10 or less within the first 24 hours after admission, were randomly assigned to a double-blind, placebo-controlled, crossover design trial. MAIN OUTCOME MEASURES Amantadine, 200 mg, or placebo was each administered for 6 weeks (12 weeks total) to patients who were recruited consecutively. RESULTS There was an improvement in the Mini-Mental Status (MMSE) scores of 14.3 points (P =.0185), Disability Rating Scale (DRS) score of 9.8 points (P =.0022), Glasgow Outcome Scale (GOS) score of 0.8 points (P =.0077), and in the FIM Cognitive score (FIM-cog) of 15.1 points (P =.0033) in the group that received amantadine during the first 6 weeks (group 1), but there was no improvement in the second 6 weeks on placebo (P >.05). In group 2 (active drug second 6 weeks), there was an improvement in the MMSE of 10.5 points, in the DRS of 9.4 points (P =.0006), in the GOS of 0.5 points (P =.0231), and in the FIM-cog of 11.3 points (P =.0030, Wilcoxon signed rank) spontaneously in the first 6 weeks on placebo (P =.0015). However, group 2 gained a statistically significant additional 6.3 points of recovery in the MMSE (P =.0409), 3.8 points in the DRS (P =.0099), 0.5 points in the GOS (P =.4008), and 5.2 points in the FIM-cog (P =.0173, Wilcoxon signed rank) between the sixth week and the twelfth week of treatment on the active drug. CONCLUSIONS There was a consistent trend toward a more rapid functional improvement regardless of when a patient with DAI-associated TBI was started on amantadine in the first 3 months after injury.
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Affiliation(s)
- Jay M Meythaler
- Department of Physical Medicine & Rehabilitation, Spain Rehabilitation Center R157, School of Medicine, University of Alabama at Birmingham, 619 6th Avenue, Birmingham, AL 35249-7330, USA.
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Meythaler JM, Peduzzi JD, Eleftheriou E, Novack TA. Current concepts: diffuse axonal injury-associated traumatic brain injury. Arch Phys Med Rehabil 2001; 82:1461-71. [PMID: 11588754 DOI: 10.1053/apmr.2001.25137] [Citation(s) in RCA: 329] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To review the probable physical, physiologic mechanisms that result in the medical and neuropsychologic complications of diffuse axonal injury (DAI)-associated traumatic brain injury (TBI). DATA SOURCES Various materials were accessed: MEDLINE, textbooks, scientific presentations, and current ongoing research that has been recently reported. STUDY SELECTION Included were scientific studies involving TBI, particularly direct injury to the axons and glia of the central nervous system (CNS) in both in vitro and in vivo models. These studies include pathologic findings in humans as well as the medical complications and behavioral outcomes of DAI. Studies that addressed animal models of DAI as well as cellular and/or tissue models of neuronal injury were emphasized. The review also covered work on the physical properties of materials involved in the transmission of energy associated with prolonged acceleration-deceleration injuries. DATA EXTRACTION Studies were selected with regard to those that addressed the mechanism of TBI associated with DAI and direct injury to the axon within the CNS. The material was generally the emphasis of the article and was extracted by multiple observers. Studies that correlate the above findings with the clinical picture of DAI were included. DATA SYNTHESIS Concepts were developed by the authors based on the current scientific findings and theories of DAI. The synthesis of these concepts involves expertise in physical science, basic science concepts of cellular injury to the CNS, acute medical indicators of DAI, neuropsychologic indicators of DAI, and rehabilitation outcomes from TBI. CONCLUSIONS The term DAI is a misnomer. It is not a diffuse injury to the whole brain, rather it is predominant in discrete regions of the brain following high-speed, long-duration deceleration injuries. DAI is a consistent feature of TBI from transportation-related injuries as well as some sports injuries. The pathology of DAI in humans is characterized histologically by widespread damage to the axons of the brainstem, parasagittal white matter of the cerebral cortex, corpus callosum, and the gray-white matter junctions of the cerebral cortex. Computed tomography and magnetic resonance imaging scans taken initially after injury are often normal. The deformation of the brain due to plastic flow of the neural structures associated with DAI explains the micropathologic findings, radiologic findings, and medical and neuropsychologic complications from this type of injury mechanism. There is evidence that the types of cellular injury in TBI (DAI, anoxic, contusion, hemorrhagic, perfusion-reperfusion) should be differentiated, as all may involve different receptors and biochemical pathways that impact recovery. These differing mechanisms of cellular injury involving specific biochemical pathways and locations of injury may, in part, explain the lack of success in drug trials to ameliorate TBI.
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Affiliation(s)
- J M Meythaler
- Department of Physical Medicine and Rehabilitation, University of Alabama at Birmingham School of Medicine, 35249-7330, USA.
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