1
|
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.
Collapse
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
| |
Collapse
|
2
|
Alshaya AI, Aldhaeefi M, Alodhaiyan N, Alqahtani M, Althewaibi S, Alshahrani W, Al Sulaiman K, Al Harbi SA, Vishwakarma R, Aldabbagh T. Clonidine safety and effectiveness in the management of suspected paroxysmal sympathetic hyperactivity post-traumatic brain injury: A retrospective cohort study. Sci Prog 2023; 106:368504231201298. [PMID: 37933150 PMCID: PMC10631352 DOI: 10.1177/00368504231201298] [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] [Indexed: 11/08/2023]
Abstract
INTRODUCTION Traumatic brain injury (TBI) is a leading cause of mortality and morbidity worldwide. In addition, TBI may cause paroxysmal sympathetic hyperactivity (PSH), which is associated with poor clinical outcomes. This study aimed to evaluate the safety and effectiveness of clonidine in patients with TBI and suspected PSH. METHODS A retrospective cohort study for critically ill patients with TBI with suspected PSH admitted to intensive care units (ICUs) from 1 May 2016 to 31 January 2020 at a tertiary academic medical center. Eligible patients were categorized based on clonidine use during their ICU stay (Clonidine group vs. Control group). The primary outcome was the improvement in functional outcomes during ICU stay, defined by a delta Glasgow Coma Score (GCS). Secondary outcomes included ICU and hospital length of stay, heart rate variation, and 90-day mortality. RESULTS A total of 2915 patients were screened, of which 169 were included. Based on multiple regression analysis, patients who received clonidine showed better improvement in functional outcomes by a higher mean delta GCS than patients who did not (Beta Coeff. 0.41; CI: 0.07 - 0.74; P = 0.02). In addition, the patient's GCS upon ICU discharge and IV opioids requirement on day three were higher in the clonidine group than control (beta coefficient (95% CI): 0.18 (0.03, 0.32); p = 0.02 and beta coefficient (95% CI): 1.38 (0.24, 2.52); p = 0.02, respectively). No statistical differences were observed in any of the other secondary outcomes after adjusting for confounders. CONCLUSION This study found that patients who received clonidine had better functional outcomes during their ICU stay, as shown by their delta GCS than those who did not. Other outcomes were similar between the groups. More data are needed to explore the role of clonidine in patients with TBI with suspected PSH.
Collapse
Affiliation(s)
- Abdulrahman I Alshaya
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Pharmaceutical Care Services, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Mohammed Aldhaeefi
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Pharmaceutical Care Services, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- Department of Clinical and Administrative Pharmacy Sciences, College of Pharmacy, Howard University, Washington, USA
| | - Nada Alodhaiyan
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Maha Alqahtani
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Sarah Althewaibi
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Wala Alshahrani
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Khalid Al Sulaiman
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Pharmaceutical Care Services, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Shmeylan A. Al Harbi
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Pharmaceutical Care Services, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Ramesh Vishwakarma
- Statistics Department, European Organization for Research and Treatment of Cancer (EORTC) Headquarters, Brussels, Belgium
| | - Tariq Aldabbagh
- Department of Critical Care, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| |
Collapse
|
3
|
Schoch K, McConkie-Rosell A, Walley N, Bhambhani V, Feyma T, Pizoli CE, Smith EC, Tan QKG, Shashi V. Parental perspectives of episodic irritability in an ultra-rare genetic disorder associated with NACC1. Orphanet J Rare Dis 2023; 18:269. [PMID: 37667351 PMCID: PMC10476425 DOI: 10.1186/s13023-023-02891-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 08/25/2023] [Indexed: 09/06/2023] Open
Abstract
BACKGROUND A recurrent de novo variant (c.892C>T) in NACC1 causes a neurodevelopmental disorder with epilepsy, cataracts, feeding difficulties, and delayed brain myelination (NECFM). An unusual and consistently reported feature is episodic extreme irritability and inconsolability. We now characterize these episodes, their impact on the family, and ascertain treatments that may be effective. Parents of 14 affected individuals provided narratives describing the irritability episodes, including triggers, behavioral and physiological changes, and treatments. Simultaneously, parents of 15 children completed the Non-communicating Children's Pain Checklist-Revised (NCCPC-R), a measure to assess pain in non-verbal children. RESULTS The episodes of extreme irritability include a prodromal, peak, and resolving phase, with normal periods in between. The children were rated to have extreme pain-related behaviors on the NCCPC-R scale, although it is unknown whether the physiologic changes described by parents are caused by pain. Attempted treatments included various classes of medications, with psychotropic and sedative medications being most effective (7/15). Nearly all families (13/14) describe how the episodes have a profound impact on their lives. CONCLUSIONS NECFM caused by the recurrent variant c.892C>T is associated with a universal feature of incapacitating episodic irritability of unclear etiology. Further understanding of the pathophysiology can lead to more effective therapeutic strategies.
Collapse
Affiliation(s)
- Kelly Schoch
- Division of Medical Genetics, Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Allyn McConkie-Rosell
- Division of Medical Genetics, Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Nicole Walley
- Division of Medical Genetics, Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Vikas Bhambhani
- Division of Genetics and Genomic Medicine, Children's Hospital and Clinics of Minnesota, Minneapolis, MN, USA
| | - Timothy Feyma
- Gillette Children's Specialty Healthcare, Saint Paul, MN, USA
| | - Carolyn E Pizoli
- Division of Neurology, Department of Pediatrics, Duke University School of Medicine, Durham, NC, 27710, USA
| | - Edward C Smith
- Division of Neurology, Department of Pediatrics, Duke University School of Medicine, Durham, NC, 27710, USA
| | - Queenie K-G Tan
- Division of Medical Genetics, Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Vandana Shashi
- Division of Medical Genetics, Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA.
| |
Collapse
|
4
|
Qu X, Hou X, Zhu K, Chen W, Chen K, Sang X, Wang C, Zhang Y, Xu H, Wang J, Hou Q, Lv L, Hou L, Zhang D. Neutrophil extracellular traps facilitate sympathetic hyperactivity by polarizing microglia toward M1 phenotype after traumatic brain injury. FASEB J 2023; 37:e23112. [PMID: 37534961 DOI: 10.1096/fj.202300752r] [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: 04/16/2023] [Revised: 06/05/2023] [Accepted: 07/13/2023] [Indexed: 08/04/2023]
Abstract
Traumatic brain injury (TBI), particularly diffuse axonal injury (DAI), often results in sympathetic hyperactivity, which can exacerbate the prognosis of TBI patients. A key component of this process is the role of neutrophils in causing neuroinflammation after TBI by forming neutrophil extracellular traps (NETs), but the connection between NETs and sympathetic excitation following TBI remains unclear. Utilizing a DAI rat model, the current investigation examined the role of NETs and the HMGB1/JNK/AP1 signaling pathway in this process. The findings revealed that sympathetic excitability intensifies and peaks 3 days post-injury, a pattern mirrored by the activation of microglia, and the escalated NETs and HMGB1 levels. Subsequent in vitro exploration validated that HMGB1 fosters microglial activation via the JNK/AP1 pathway. Moreover, in vivo experimentation revealed that the application of anti-HMGB1 and AP1 inhibitors can mitigate microglial M1 polarization post-DAI, effectively curtailing sympathetic hyperactivity. Therefore, this research elucidates that post-TBI, NETs within the PVN may precipitate sympathetic hyperactivity by stimulating M1 microglial polarization through the HMGB1/JNK/AP1 pathway.
Collapse
Affiliation(s)
- Xiaolin Qu
- Department of Neurosurgery, Changzheng Hospital, Naval Medical University, Shanghai, China
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiaoxiang Hou
- Department of Neurosurgery, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Kaixin Zhu
- Department of Neurosurgery, Changzheng Hospital, Naval Medical University, Shanghai, China
- Department of Neurosurgery, The First Naval Hospital of Southern Theater Command, Zhanjiang, China
| | - Wen Chen
- Department of Neurosurgery, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Kun Chen
- Department of Neurosurgery, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Xianzheng Sang
- Department of Neurosurgery, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Chenqing Wang
- Department of Neurosurgery, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Yelei Zhang
- Department of Neurosurgery, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Haoxiang Xu
- Department of Neurosurgery, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Junyu Wang
- Department of Neurosurgery, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Qibo Hou
- College of Liberal Arts and Sciences, University of Illinois Urbana-Champaign, Urbana, Illinois, USA
| | - Liquan Lv
- Department of Neurosurgery, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Lijun Hou
- Department of Neurosurgery, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Danfeng Zhang
- Department of Neurosurgery, Changzheng Hospital, Naval Medical University, Shanghai, China
| |
Collapse
|
5
|
Hudoba C, Kirsch HL, Malotte KL, Kramer NM. Paroxysmal Sympathetic Hyperactivity #458. J Palliat Med 2023; 26:870-872. [PMID: 37276519 DOI: 10.1089/jpm.2023.0048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023] Open
|
6
|
Seo W. Paroxysmal Sympathetic Hyperactivity After Acquired Brain Injury: An Integrative Literature Review. Crit Care Nurse 2023; 43:12-19. [PMID: 36720279 DOI: 10.4037/ccn2023610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Paroxysmal sympathetic hyperactivity may occur in patients with acute brain injury and is associated with physical disability, poor clinical outcomes, prolonged hospitalization, and higher health care costs. OBJECTIVE To comprehensively review current literature and provide information about paroxysmal sympathetic hyperactivity for nurses. METHODS An integrative literature review was conducted according to Whittemore and Knafl's method. The search was conducted from October 2020 through January 2021. The main targets of the literature search were definition, incidence rate, causes, clinical characteristics, pathophysiology, diagnosis, and treatment of paroxysmal sympathetic hyperactivity in pediatric and adult patients. The results were reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS The most characteristic clinical features of paroxysmal sympathetic hyperactivity are hypertension, tachycardia, tachypnea, hyperthermia, diaphoresis, and abnormal motor posturing. Reported incidence rates of paroxysmal sympathetic hyperactivity in patients with brain injury range from 8% to 33%. Various diagnostic criteria have been proposed; most are based on clinical symptoms. Ruling out other causes of the signs and symptoms of paroxysmal sympathetic hyperactivity is important because the signs and symptoms are nonspecific. The major goals of paroxysmal sympathetic hyperactivity management are avoidance of stimuli that may trigger a paroxysmal episode, inhibition of sympathetic overactivity, and prevention of damage to other organs. CONCLUSIONS Critical care nurses should be aware of the signs and symptoms of paroxysmal sympathetic hyperactivity in patients with acute brain injury. Early identification is important to ensure timely treatment for patients with paroxysmal sympathetic hyperactivity.
Collapse
Affiliation(s)
- WhaSook Seo
- WhaSook Seo is a professor at Inha University Department of Nursing, Incheon, Republic of Korea
| |
Collapse
|
7
|
Neurocritical Care Pharmacology. Neurocrit Care 2022. [DOI: 10.1017/9781108907682.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
8
|
Sakai K, Kitagawa T, Suzuki K, Toh K, Yamamoto J. Paroxysmal sympathetic hyperactivity following acute diffuse brain swelling due to traumatic brain injury: a case report with good clinical outcome. EGYPTIAN JOURNAL OF NEUROSURGERY 2022. [DOI: 10.1186/s41984-022-00146-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Paroxysmal sympathetic hyperactivity (PSH) may occur after acquired brain injury. The clinical presentation of PSH results from increased sympathetic overdrive, including transient paroxysms of tachycardia, hypertension, hyperventilation, hyperthermia, dystonic posturing, and excessive sweating. The exact pathophysiology of PSH, however, remains unclear, and no definitive treatment is available. Herein, the authors report a case of PSH in a male patient who experienced acute brain swelling after acquired head injury, for which a good clinical outcome was achieved due to multimodal treatment. The ensuing discussion also addresses the pathophysiology of PSH.
Case presentation
An 18-year-old man was transported to the authors’ hospital after experiencing a traumatic brain injury. On admission, computed tomography revealed cerebral herniation due to diffuse brain edema in the left parietal lobe. Emergency decompressive craniotomy and internal decompression were performed. After surgery, anti-edema therapy (glycerol and mannitol) was continued. Ten days postoperatively, PSH was diagnosed in accordance with the PSH assessment score (20 points). Vecuronium, fentanyl, morphine, propofol, dexmedetomidine, and a calcium channel blocker were administered; however, the drug effect was insufficient. Thirty-two days postsurgery, the patient gradually recovered from the adrenergic symptoms of PSH, and head computed tomography performed 32 days after surgery revealed improvement in diffuse brain edema. Ultimately, the patient fully recovered and lived independently at home.
Conclusions
Considering the pathophysiology of PSH, cerebral contusion, acute brain swelling, and secondary mechanisms of brain injury may trigger sympathetic nerve-enhancing regions and cause hyperexcitation of the sympathetic nervous system, resulting in PSH. The outcome of the present case demonstrates that PSH can be reversed if it is identified early and before it becomes irreversible, that is, post the development of hypoxic encephalopathy or widespread brain damage. Appropriate management, including decompression craniotomy for brain swelling and multidisciplinary treatment, leads to good clinical outcomes.
Collapse
|
9
|
Jafari AA, Shah M, Mirmoeeni S, Hassani MS, Nazari S, Fielder T, Godoy DA, Seifi A. Paroxysmal sympathetic hyperactivity during traumatic brain injury. Clin Neurol Neurosurg 2021; 212:107081. [PMID: 34861468 DOI: 10.1016/j.clineuro.2021.107081] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 11/22/2021] [Accepted: 11/25/2021] [Indexed: 11/26/2022]
Abstract
Traumatic brain injury (TBI) is one of the leading causes of disability, morbidity, and mortality worldwide. Some of the more common etiologies of TBI include closed head injury, penetrating head injury, or an explosive blast head injury. Neuronal damage in TBI is related to both primary injury (caused by mechanical forces), and secondary injury (caused by the subsequent tissue and cellular damages). Recently, it has been well established that Paroxysmal Sympathetic Hyperactivity (PSH), also known as "Sympathetic Storm", is one of the main causes of secondary neuronal injury in TBI patients. The clinical manifestations of PSH include recurrent episodes of sympathetic hyperactivity characterized by tachycardia, systolic hypertension, hyperthermia, tachypnea with hyperpnea, and frank diaphoresis. Given the diverse manifestations of PSH and its notable impact on the outcome of TBI patients, we have comprehensively reviewed the current evidence and discussed the pathophysiology, clinical manifestations, time of onset and duration of PSH during TBI. This article reviews the different types of head injuries that most commonly lead to PSH, possible approaches to manage and minimize PSH complications in TBI and the current prognosis and outcomes of PSH in TBI patients.
Collapse
Affiliation(s)
- Amirhossein Azari Jafari
- Student Research Committee, School of Medicine, Shahroud University of Medical Sciences, Shahroud, Iran
| | - Muffaqam Shah
- Deccan College of Medical Sciences, Hyderabad, Telangana State, India
| | | | - Maryam Sadat Hassani
- Student Research Committee, School of Medicine, Shahroud University of Medical Sciences, Shahroud, Iran
| | - Shahrzad Nazari
- Department of Neuroscience and Addiction Studies, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Tristan Fielder
- University of Texas Health Science Center at San Antonio School of Medicine, San Antonio, TX, USA
| | - Daniel Agustin Godoy
- Neurointensive Care Unit, Sanatorio Pasteur; Hospital Carlos Malbran, Catamarca, Argentina
| | - Ali Seifi
- Department of Neurosurgery, Division of Neuro Critical Care, University of Texas Health Science Center at San Antonio School of Medicine, San Antonio, TX, USA.
| |
Collapse
|
10
|
Paroxysmal Sympathetic Hyperactivity in Moderate-to-Severe Traumatic Brain Injury and the Role of Beta-Blockers: A Scoping Review. Emerg Med Int 2021; 2021:5589239. [PMID: 34545310 PMCID: PMC8449736 DOI: 10.1155/2021/5589239] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 04/08/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction Most cases of paroxysmal sympathetic hyperactivity (PSH) result from traumatic brain injury (TBI). Little is known about its pathophysiology and treatment, and several neuroprotective drugs are used including beta-blockers. The aim of our study is to collate existing evidence of the role of beta-blockers in the treatment of PSH. Methods We searched MEDLINE, ResearchGate, and Google Scholar, for keywords related to PSH and the role of beta-blockers in moderate-to-severe TBI on September 23, 2020. Two authors blindly screened the articles found with Rayyan. Both resolved their conflicts by mutual consent. If no solution was found, a third author was consulted. Simple descriptive data analysis was performed and the results were presented both in a narrative and tabular form. Results Of the 19 items found, 10 met the criteria for inclusion. 50% were systematic reviews without meta-analysis, 40% were observational studies, and 10% were experimental studies. Propranolol was the main beta-blocker found in 80% of the studies and was the only molecule used in the treatment of paroxysmal sympathetic hyperactivity in 40% of the included studies. Only two studies evaluated and showed a significant association between beta-blockers and mortality rate (5.1% vs. 10.8%; P=0.03), (3% vs. 15%; P=0.002), respectively. Conclusion Propranolol is the beta-blocker that has been shown to be effective in reducing the length of stay and mortality rate in moderate-severe traumatic brain injury patients with PSH. However, further studies are needed to precisely define the terms and conditions of its use.
Collapse
|
11
|
Bhardwaj A, Satapathy GC, Garg A, Chawla V, Jangra K. Incidence of Paroxysmal Sympathetic Hyperactivity after Traumatic Brain Injury in a Tertiary Care ICU: A Retrospective Cohort Study. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2021. [DOI: 10.1055/s-0040-1721553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Abstract
Background Paroxysmal sympathetic hyperactivity (PSH) is an understudied complication of traumatic brain injury (TBI). PSH usually presents with transient rise in sympathetic outflow, leading to increased blood pressure, heart rate, temperature, respiratory rate, sweating, and posturing activity. We retrospectively analyzed the incidence of PSH in TBI using PSH-assessment measure (PSH-AM) scale.
Methods This single-center retrospective cohort study was conducted in traumatic head injury patients admitted in the intensive care unit from January 1, 2016 to December 31, 2019 in a tertiary care center. The data was collected from the hospital database after obtaining approval from the hospital ethics committee.
Results A total of 287 patients (18–65 years of age) were admitted to intensive care unit (ICU) with TBI out of which 227 patients were analyzed who had ICU stay for more than 14 days. PSH was diagnosed in 70 (30.8%) patients. Mean age of PSH positive patients was 40 ± 18 and 49 ± 11 years for PSH negative patients (p < 0.001). The age group between 40 and 50 years had a higher incidence of PSH. The age and Glasgow coma score (GCS) were significantly associated with the occurrence of PSH. The GCS score demonstrated good accuracy for predicting the occurrence of PSH with AUC 0.83, 95% CI of 0.775 to 0.886, and a p-value of 0.001.
Conclusion We observed that the incidence of PSH was 30.8% in the patients with TBI. Age and GCS were found to have a significant association for predicting the occurrence of PSH. The patients who developed PSH had a longer length of hospital stay in ICU.
Collapse
Affiliation(s)
- Ajit Bhardwaj
- Department of Anaesthesia, Critical Care Command Hospital, Lucknow, Uttar Pradesh, India
| | - Ganesh C. Satapathy
- Department of Anaesthesia, Critical Care Command Hospital, Lucknow, Uttar Pradesh, India
| | - Arpit Garg
- Department of Anaesthesia, Critical Care Command Hospital, Lucknow, Uttar Pradesh, India
| | - Vikas Chawla
- Department of Anaesthesia, Critical Care Command Hospital, Lucknow, Uttar Pradesh, India
| | - Kiran Jangra
- Department of Anesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
12
|
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.
Collapse
|
13
|
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.
Collapse
|
14
|
Vázquez Sánchez T, Gámez España JP, Martínez Esteban MD. [HYpertension due to sympathetic hyperactivity after severe head injury]. HIPERTENSION Y RIESGO VASCULAR 2020; 38:44-47. [PMID: 32605890 DOI: 10.1016/j.hipert.2020.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 06/03/2020] [Accepted: 06/06/2020] [Indexed: 11/18/2022]
Abstract
We present the case of a 34-year-old patient with severe head trauma and severe brain involvement. The patient deteriorated progressively and required several reinterventions for bleeding and brain herniation. We were consulted by neurosurgery due to irregular blood pressure control despite treatment with calcium antagonists. The patient had associated diaphoresis, tachypnoea and tachycardia, together with persistent high-grade fever with no microbiological evidence. Laboratory tests showed normal kidney function, with no proteinuria and no signs of left ventricular hypertrophy to suggest previous arterial hypertension. This led us to consider sympathetic hyperactivity syndrome as a first possible diagnosis due to severe neurological damage. In line with this suspicion, antihypertensive therapy was initiated which included non-cardioselective beta-blockers, alpha-2 agonists, benzodiazepines and GABA receptor agonists. Thus, we were able to improve the labile blood pressure levels, which supports the diagnosis.
Collapse
Affiliation(s)
- T Vázquez Sánchez
- Unidad de Gestión Clínica de Nefrología, Hospital Regional Universitario de Málaga, Universidad de Málaga, Instituto Biomédico de Investigación de Málaga (IBIMA), REDinREN (RD16/0009/0006), Málaga, España.
| | - J P Gámez España
- Unidad de Gestión Clínica de Nefrología, Hospital Regional Universitario de Málaga, Universidad de Málaga, Instituto Biomédico de Investigación de Málaga (IBIMA), REDinREN (RD16/0009/0006), Málaga, España
| | - M D Martínez Esteban
- Unidad de Gestión Clínica de Nefrología, Hospital Regional Universitario de Málaga, Universidad de Málaga, Instituto Biomédico de Investigación de Málaga (IBIMA), REDinREN (RD16/0009/0006), Málaga, España
| |
Collapse
|
15
|
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.
Collapse
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
| |
Collapse
|
16
|
Suer M, Abd-Elsayed A. Patient with Traumatic Brain Injury. GUIDE TO THE INPATIENT PAIN CONSULT 2020:429-443. [DOI: 10.1007/978-3-030-40449-9_29] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
|