Neurogenic Fever

Overlapping Physiologic Signs of Sepsis and Paroxysmal Sympathetic Hyperactivity After Traumatic Brain Injury: Exploring A Clinical Conundrum

BACKGROUND

Paroxysmal sympathetic hyperactivity (PSH) occurs in a subset of patients with traumatic brain injury (TBI) and is associated with worse outcomes. Sepsis is also associated with worse outcomes after TBI and shares several physiologic features with PSH, potentially creating diagnostic confusion and suboptimal management of each. This is the first study to directly investigate the interaction between PSH and infection using robust diagnostic criteria.

METHODS

We performed a retrospective cohort study of patients with TBI admitted to a level I trauma center intensive care unit with hospital length of stay of at least 2 weeks. From January 2016 to July 2018, 77 patients diagnosed with PSH were 1:1 matched by age and Glasgow Coma Scale to 77 patients without PSH. Trauma infectious diseases subspecialists prospectively documented assessments corroborating diagnoses of infection. Extracted data including incidence, timing, classification, and anatomical source of infections were compared according to PSH diagnosis. We also evaluated daily PSH clinical feature severity scores and systemic inflammatory response syndrome (SIRS) criteria and compared values for patients with and without confirmed infection, stratified by PSH diagnosis.

RESULTS

During the first 2 weeks of hospitalization, there were no differences in rates of suspected (62%) nor confirmed (48%) infection between patients with PSH and controls. Specific treatments for PSH were initiated on median hospital day 7 and for confirmed infections on median hospital day 8. SIRS criteria could identify infection only in patients who were not diagnosed with PSH.

CONCLUSIONS

In the presence of brain injury-induced autonomic nervous system dysregulation, the initiation and continuation of antimicrobial therapy is a challenging clinical decision, as standard physiologic markers of sepsis do not distinguish infected from noninfected patients with PSH, and these entities often present around the same time. Clinicians should be aware that PSH is a potential driver of SIRS, and familiarity with its diagnostic criteria as proposed by the PSH assessment measure is important. Management by a multidisciplinary team attentive to these issues may reduce rates of inappropriate antibiotic usage and misdiagnoses.

Hypothermia on the first day of ICU admission leads to increased in-hospital mortality in patients with subarachnoid hemorrhage

The relationship between early spontaneous hypothermia and adverse clinical outcomes in patients with subarachnoid hemorrhage (SAH) has not been paid much attention. We designed this retrospective cohort study to determine this relationship by analyzing the association between the lowest body temperature (T-lowest) on the first day of ICU admission and in-hospital mortality. In this study, 550 participants with non-traumatic SAH were chosen from the Medical Information Mart for Intensive Care (MIMIC)-IV database. Multivariate Cox regression analysis showed that T-lowest was nonlinearity correlated with in-hospital mortality (HR = 0.72, 95% CI: 0.59-0.86, p < 0.001). We divided the T-lowest into quartile groups. In comparison to reference group Q1 (31.30-36.06 ℃), group Q3 (36.56-36.72 ℃) had a 50% lower risk of death in the hospital (HR: 0.5, 95% CI: 0.28-0.87, p = 0.014). We further confirmed the curve-like relationship between T-lowest and in-hospital mortality using restricted cubic splines. The mortality is lowest when the T-lowest is close to 36.5 °C, and the risk of death is increased when the temperature is lower or higher than that. Our study demonstrates that in-hospital mortality is associated with T-lowest. Patients with non-traumatic SAH are at increased risk of death if their body temperature on the first day of ICU admission is too low.

Adverse Effect of Neurogenic, Infective, and Inflammatory Fever on Acutely Injured Human Spinal Cord

This study aims to determine the effect of neurogenic, inflammatory, and infective fevers on acutely injured human spinal cord. In 86 patients with acute, severe traumatic spinal cord injuries (TSCIs; American Spinal Injury Association Impairment Scale (AIS), grades A-C) we monitored (starting within 72 h of injury, for up to 1 week) axillary temperature as well as injury site cord pressure, microdialysis (MD), and oxygen. High fever (temperature ≥38°C) was classified as neurogenic, infective, or inflammatory. The effect of these three fever types on injury-site physiology, metabolism, and inflammation was studied by analyzing 2864 h of intraspinal pressure (ISP), 1887 h of MD, and 840 h of tissue oxygen data. High fever occurred in 76.7% of the patients. The data show that temperature was higher in neurogenic than non-neurogenic fever. Neurogenic fever only occurred with injuries rostral to vertebral level T4. Compared with normothermia, fever was associated with reduced tissue glucose (all fevers), increased tissue lactate to pyruvate ratio (all fevers), reduced tissue oxygen (neurogenic + infective fevers), and elevated levels of pro-inflammatory cytokines/chemokines (infective fever). Spinal cord metabolic derangement preceded the onset of infective but not neurogenic or inflammatory fever. By considering five clinical characteristics (level of injury, axillary temperature, leukocyte count, C-reactive protein [CRP], and serum procalcitonin [PCT]), it was possible to confidently distinguish neurogenic from non-neurogenic high fever in 59.3% of cases. We conclude that neurogenic, infective, and inflammatory fevers occur commonly after acute, severe TSCI and are detrimental to the injured spinal cord with infective fever being the most injurious. Further studies are required to determine whether treating fever improves outcome. Accurately diagnosing neurogenic fever, as described, may reduce unnecessary septic screens and overuse of antibiotics in these patients.

Antipyretic Efficacy of Bromocriptine in Central Fever: an Exploratory Analysis

BACKGROUND

'Central' fevers are thought to result from disruption of hypothalamic thermoregulatory pathways following severe brain injuries. Bromocriptine, due to its central dopamine receptor agonism, has been hypothesized to have antipyretic effect in this setting. However, clinical evidence for this off-label use is limited to a few case reports. In this retrospective cohort study, we analyzed the effect of bromocriptine administration on body temperature in acute brain injury patients with suspected central fever.

METHODS

We screened a cohort of adult patients that received bromocriptine in the neurologic-intensive care unit of a tertiary care hospital between January 2018 and December 2021. Indication of central fever was ascertained by review of clinical documentation. A generalized additive mixed model (GAMM) was used to model temperature as a function of time relative to bromocriptine initiation. We adjusted for potential confounding due to the following covariates: temperature recording method (invasive vs surface), concurrent antipyretic administration within 8 h, and surface cooling device use within 4 h of temperature measurement. Temperature-time function was modeled using a cubic spline with k = 10 knots.

RESULTS

A total of 33 patients were included in the analysis (14 women; mean age: 50 y, standard deviation 14 y). Median dose of bromocriptine was 7.5 mg (range 2.5-40) for a median of 13 d (range 5-160). Age and sex did not impact the function of temperature over time. Predicted temperatures were significantly (p < 0.05) higher by 0.4 °C with invasive compared to surface recording methods, lower by 0.2 °C in the presence of cooling device use and lower by 0.1 °C with concurrent antipyretic use. On adjusted analysis with the GAMM, there was decline (p < 0.05) in temperature following bromocriptine initiation by - 0.3 °C at 24 h, - 0.5 °C at 48 h, and - 0.7 °C at 72 h.

CONCLUSIONS

Bromocriptine use was associated with modest but statistically significant decline in temperature, with nadir at 72 h post initiation. The findings provide a data driven basis for prospective evaluation.

Temperature Changes in Poor-Grade Aneurysmal Subarachnoid Hemorrhage: Relation to Injury Pattern, Intracranial Pressure Dynamics, Cerebral Energy Metabolism, and Clinical Outcome

BACKGROUND

The aim was to study the course of body temperature in the acute phase of poor-grade aneurysmal subarachnoid hemorrhage (aSAH) in relation to the primary brain injury, cerebral physiology, and clinical outcome.

METHODS

In this observational study, 166 patients with aSAH treated at the neurosurgery department at Uppsala University Hospital in Sweden between 2008 and2018 with temperature, intracranial pressure (ICP), and microdialysis (MD) monitoring were included. The first 10 days were divided into the early phase (days 1-3) and the vasospasm phase (days 4-10).

RESULTS

Normothermia (temperature = 36-38 °C) was most prevalent in the early phase. A lower mean temperature at this stage was univariately associated with a worse primary brain injury, with higher Fisher grade and higher MD glycerol concentration, as well as a worse neurological recovery at 1 year. There was otherwise no association between temperature and cerebral physiological variables in the early phase. There was a transition toward an increased burden of hyperthermia (temperature > 38 °C) in the vasospasm phase. This was associated with concurrent infections but not with neurological or radiological injury severity at admission. Elevated temperature was associated with higher MD pyruvate concentration, lower rate of an MD pattern indicative of ischemia, and higher rate of poor neurological recovery at 1 year. There was otherwise no association between temperature and cerebral physiological variables in the vasospasm phase. The associations between temperature and clinical outcome did not hold true in multiple logistic regression analyses.

CONCLUSIONS

Spontaneously low temperature in the early phase reflected a worse primary brain injury and indicated a worse outcome prognosis. Hyperthermia was common in the vasospasm phase and was more related to infections than primary injury severity but also with a more favorable energy metabolic pattern with better substrate supply, possibly related to hyperemia.

The Value of CD64 in the Early Diagnosis for Intracranial Infection After Craniocerebral Surgery

PURPOSE

To investigate the value of CD64 in the early diagnosis of intracranial infection after craniocerebral surgery.

METHODS

A total of 93 patients who met the inclusion and exclusion criteria after neurosurgery in Lianyungang First People's Hospital and Lianyungang Second People's Hospital were admitted and divided into experimental group with intracranial infection (n = 32) and uninfected control group (n = 61) according to the results of cerebrospinal fluid culture. We performed relevant statistical analysis, drew the receiver operating characteristic curve and calculated area under the curve (AUC).

RESULTS

The sensitivity and specificity of the CD64, c-reactive protein (CRP), and white blood cell (WBC) counts were 84.38% and 86.89%, 78.13% and 75.41%, and 75.00% and 67.21%, respectively; the AUCs were 0.912, 0.858, and 0.851, respectively. Accuracy was the highest when the 3 diagnosis were combined, reaching 93.75%; the AUC could reach 0.948.

CONCLUSIONS

Serum CD64, CRP, and WBC count in the diagnosis of intracranial infection after craniocerebral surgery were significant. CD64 was more valuable than the others. The diagnostic efficiency could be improved when CD64, CRP, and WBC count were combined.

Neurogenic Fever after Subarachnoid Hemorrhage in Animal Models: A Systematic Review

The observation of neurogenic fever resulting from subarachnoid hemorrhage (SAH) in animal models is a useful tool for the interpretation of its pathophysiology in humans, which is still a major challenge in the management of neurocritical patients. This systematic review aims to identify the prognostic factors and pathophysiological elements that determine the onset of neurogenic fever and its severity in animal models. In addition, our study aims to analyze which pharmacological treatments are most effective. All the articles available in Pubmed, Embase, and the Biological Science Collection until August 2021 concerning in vivo experimental studies on SAH animal models, including full texts and abstracts written in English and Italian, were considered. The risk of bias was assessed with SYRCLE's Risk of Bias tool. In total, 81 records were retrieved; after excluding duplicates, 76 records were potentially relevant. A total of 64 articles was excluded after title and abstract screening. The remaining 12 studies were evaluated as full texts, and 6 other studies were excluded (SAH-induced animal studies without a body temperature assessment). In one study, body temperature was measured after SAH induction, but the authors did not report temperature recording. Therefore, only five studies met the search criteria. The high methodological heterogeneity (different animal species, different temperature measurement methods, and different methods of the induction of bleeding) prevented meta-analysis. Synthesis methodology without meta-analysis (SWiM) was used for data analysis. The total number of animals used as controls was 87 (23 rabbits, 32 mice, and 32 rats), while there were 130 animals used as interventions (54 rabbits, 44 mice, and 32 rats). The presence of blood in the subarachnoid space, particularly red blood cells, is responsible for neurogenic fever; the role of hemoglobin is unclear. The mechanism is apparently not mediated by prostaglandins. The autonomic nervous system innervating brown adipose tissue is undoubtedly implicated in the onset of neurogenic fever. The activation of the central adenosine-1 receptor is effective in controlling the temperature of animals with neurogenic fever (by inhibiting thermogenesis of brown adipose tissue).

Systemic Inflammation after Aneurysmal Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage (aSAH) is one of the most severe neurological disorders, with a high mortality rate and severe disabling functional sequelae. Systemic inflammation following hemorrhagic stroke may play an important role in mediating intracranial and extracranial tissue damage. Previous studies showed that various systemic inflammatory biomarkers might be useful in predicting clinical outcomes. Anti-inflammatory treatment might be a promising therapeutic approach for improving the prognosis of patients with aSAH. This review summarizes the complicated interactions between the nervous system and the immune system.

Diclofenac Sodium for Fever Control in Neurocritical Care: A Systematic Review

BACKGROUND

Fever is extremely common in neurocritical care patients and is independently associated with a worse outcome. Non-steroidal anti-inflammatory drugs (NSAIDs) lower the hypothalamic set point temperature through the inhibition of prostaglandin E2 synthesis, and they constitute a second line of pharmacological treatment for temperature control. This systematic review aims to evaluate the effectiveness of DCF in reducing body temperature and its effects on brain parameters.

METHODS

A comprehensive search of several databases was run in November 2022 in Ovid EBM (Evidence Based Medicine) Reviews, Cochrane library, Ovid Medline and Scopus (1980 onward). The outcome of interest included DCF control of body temperature and its impact on cerebral parameters.

RESULTS

A total of 113 titles were identified as potentially relevant. Six articles met eligible criteria and were reviewed. DCF induce a reduction in body temperature (MD, 1.10 [0.72, 1.49], p < 0.00001), a slight decrease in ICP (MD, 2.22 [-0.25, 4.68] IC 95%; p < 0.08) as well as in CPP and MAP (MD, 5.58 [0.43, 10.74] IC 95%; p < 0.03). The significant heterogeneity and possibility of publication bias reduces the strength of the available evidence.

CONCLUSIONS

Diclofenac sodium is effective in reducing body temperature in patients with brain injury, but data in the literature are scarce and further studies are needed to evaluate the benefits of DCF.

Management of traumatic brain injury in the non-neurosurgical intensive care unit: a narrative review of current evidence

Each year, approximately 70 million people suffer traumatic brain injury, which has a significant physical, psychosocial and economic impact for patients and their families. It is recommended in the UK that all patients with traumatic brain injury and a Glasgow coma scale ≤ 8 should be transferred to a neurosurgical centre. However, many patients, especially those in whom neurosurgery is not required, are not treated in, nor transferred to, a neurosurgical centre. This review aims to provide clinicians who work in non-neurosurgical centres with a summary of contemporary studies relevant to the critical care management of patients with traumatic brain injury. A targeted literature review was undertaken that included guidelines, systematic reviews, meta-analyses, clinical trials and randomised controlled trials (published in English between 1 January 2017 and 1 July 2022). Studies involving key clinical management strategies published before this time, but which have not been updated or repeated, were also eligible for inclusion. Analysis of the topics identified during the review was then summarised. These included: fundamental critical care management approaches (including ventilation strategies, fluid management, seizure control and osmotherapy); use of processed electroencephalogram monitoring; non-invasive assessment of intracranial pressure; prognostication; and rehabilitation techniques. Through this process, we have formulated practical recommendations to guide clinical practice in non-specialist centres.

Fatal Fulminant Cerebral Edema in Six Children With SARS-CoV-2 Omicron BA.2 Infection in Taiwan

Acute fulminant cerebral edema in children following SARS-CoV-2 infection has been rarely reported. Such patients frequently demonstrate rapid progression and are usually fatal. In this retrospective study, we describe the detailed clinical, laboratory, and neuroimaging features of six fatal cases in Taiwan. All patients had shock initially, five showed rapid progression to multiorgan failure and disseminated intravascular coagulation, and three developed acute respiratory distress syndromes. The inflammatory biomarkers in the first 3 days, including interleukin 6, ferritin, lactate dehydrogenase, and D-dimer, showed significant elevation in all cases. The hyperinflammatory response may play a role in the pathophysiology.

Fine tuning of neurointensive care in aneurysmal subarachnoid hemorrhage: From one-size-fits-all towards individualized care

Aneurysmal subarachnoid hemorrhage (aSAH) is a severe type of acute brain injury with high mortality and burden of neurological sequelae. General management aims at early aneurysm occlusion to prevent re-bleeding, cerebrospinal fluid drainage in case of increased intracranial pressure and/or acute hydrocephalus, and cerebral blood flow augmentation in case of delayed ischemic neurological deficits. In addition, the brain is vulnerable to physiological insults in the acute phase and neurointensive care (NIC) is important to optimize the cerebral physiology to avoid secondary brain injury. NIC has led to significantly better neurological recovery following aSAH, but there is still great room for further improvements. First, current aSAH NIC management protocols are to some extent extrapolated from those in traumatic brain injury, notwithstanding important disease-specific differences. Second, the same NIC management protocols are applied to all aSAH patients, despite great patient heterogeneity. Third, the main variables of interest, intracranial pressure and cerebral perfusion pressure, may be too superficial to fully detect and treat several important pathomechanisms. Fourth, there is a lack of understanding not only regarding physiological, but also cellular and molecular pathomechanisms and there is a need to better monitor and treat these processes. This narrative review aims to discuss current state-of-the-art NIC of aSAH, knowledge gaps in the field, and future directions towards a more individualized care in the future.

The utility of therapeutic hypothermia on cerebral autoregulation

Cerebral autoregulation (CA) dysfunction is a strong predictor of clinical outcome in patients with acute brain injury (ABI). CA dysfunction is a potential pathologic defect that may lead to secondary injury and worse functional outcomes. Early therapeutic hypothermia (TH) in patients with ABI is controversial. Many factors, including patient selection, timing, treatment depth, duration, and rewarming strategy, impact its clinical efficacy. Therefore, optimizing the benefit of TH is an important issue. This paper reviews the state of current research on the impact of TH on CA function, which may provide the basis and direction for CA-oriented target temperature management.

Transcriptomic Analysis Reveals that Activating Transcription Factor 3/c-Jun/Lgals3 Axis Is Associated with Central Diabetes Insipidus after Hypothalamic Injury

BACKGROUND

Hypothalamic injury causes several complicated neuroendocrine-associated disorders, such as water-electrolyte imbalance, obesity, and hypopituitarism. Among these, central diabetes insipidus (CDI), characterized by polyuria, polydipsia, low urine specific gravity, and deficiency of arginine vasopressin contents, is a typical complication after hypothalamic injury.

METHODS

CDI was induced by hypothalamic pituitary stalk injury in male animals. Behavioral parameters and blood sample were collected to evaluate the characteristics of body fluid metabolism imbalance. The brains were harvested for high-throughput RNA sequencing and immunostaining to identify pathophysiological changes in corresponding hypothalamic nuclei.

RESULTS

Based on transcriptomic analysis, we demonstrated the upregulation of the activating transcription factor 3 (Atf3)/c-Jun axis and identified Lgals3, a microglial activation-related gene, as the most significant target gene in response to the body fluid imbalance in CDI. Furthermore, we found that the microglia possessed elevated phagocytic ability, which could promote the elimination of arginine vasopressin neurons after hypothalamic injury.

CONCLUSION

Our findings suggested that the Atf3/c-Jun/Lgals3 axis was associated with the microglial activation, and might participate in the loss of functional arginine vasopressin neurons in CDI after hypothalamic injury.

Heparin-Induced Fever in Neurointensive Care Unit: A Rarity Yet a Possibility

Fever is considered a protective response having multitude of benefits in terms of enhancing resistance to infection, recruiting cytokines to the injured tissue, and promoting healing. In terms of an injured brain, this becomes a double-edged sword triggering an inflammatory cascade resulting in secondary brain injury. It is important to identify the etiology so that corrective measures can be taken. Here we report a case of persistent fever in a patient with Guillain-Barré syndrome, which was probably due to heparin. This is the first report of heparin-induced fever in a neurocritical care setting and third report overall.

Intravenous Versus Oral Acetaminophen Use in Febrile Neurocritical Care Patients

The use of intravenous (IV) acetaminophen (APAP) for fever has not been thoroughly studied in neurocritical care (NCC) patients, in whom a temperature of ≥38°C is associated with poor outcomes and treatment to normothermia is common practice. This retrospective study evaluated NCC patients admitted between May 1, 2012, and April 30, 2013, and received at least one dose of IV or oral (PO) APAP for a body temperature of ≥38°C. The primary aim of this study was to compare the reduction in body temperature (RIT) between IV and PO APAP, calculated as the change in temperature before and 0.5, 1, 2, 3, and 6 hours after administration. Descriptive statistics were used to assess use characteristics, and Kruskal-Wallis and Mann-Whitney U tests were used for between-group differences. There were 142 NCC patients who received a total of 405 IV APAP and 253 PO APAP doses. Seventy percent of all APAP doses resulted in a temperature of <38°C within 6 hours. The median oral body temperature before APAP was 38.8°C and 38.6°C for IV and PO APAP, respectively (p < 0.01). The median RIT at 0.5 (IV 0.25°C vs. PO 0.2°C), 1 (IV 0.4°C vs. PO 0.2°C), 2 (IV 0.7°C vs. PO 0.5°C), 3 (IV 0.9°C vs. PO 0.6°C), and 6 (IV 1°C vs. PO 0.8°C) hours was significantly greater for IV APAP than for PO APAP at all time points (p < 0.05). Patients with an acute ischemic stroke and patients with an intracerebral hemorrhage had a statistically significantly greater RIT with IV APAP therapy. IV APAP administered to febrile NCC patients was associated with a significantly greater RIT than PO, but 70% of all APAP doses resulted in a body temperature of <38°C within 6 hours. Further prospective studies are needed to determine if IV APAP improves clinical outcomes.

Evaluation of Evidence-Based Guidelines for Fever Management in Critically Ill Adult Patients With Brain Injury

PURPOSE

The aim of this study was to evaluate the effectiveness of evidence-based guidelines for fever management of critically ill adult patients with brain injury.

METHODS

We used a pretest-posttest design with 48 patients 19 years or older admitted to an intensive care unit after surgery for brain injury. We applied evidence-based guidelines only to an experimental group of 24 patients and compared with 24 control patients who did not receive evidence-based guidelines. Experimental and control groups were matched 1:1 using the Acute Physiology and Chronic Health Evaluation II score. Data included the proportion of patients with reduced fever and time to normalized temperature.

RESULTS

The proportion of patients whose temperature fell to normal after fever was 4.5 times higher in the experimental group than in the control group. The time it took the patients' highest fever to fall to normal during their intensive care unit stay was 4.84 times faster in the experimental group than in the control group (hazard ratio, 4.84; 95% confidence interval, 1.79-13.11; P = .002).

CONCLUSION

Evidence-based guidelines for fever management in patients with a brain injury can be used in nursing practice with rapid response, improving healthcare efficiency and contributing to better outcomes for critically ill patients.

Prolonged Postoperative Pyrexia and Transient Nonnephrogenic Vasopressin-Analogue-Resistant Polyuria following Endoscopic Transsphenoidal Resection of an Infundibular Epidermoid Cyst

Prolonged postoperative pyrexia (PPP) due to Mollaret's meningitis following endoscopic transsphenoidal surgery (eTSS) for an intracranial epidermoid cyst can be confused with postoperative meningeal infection after transsphenoidal resection, especially in the middle of the COVID-19 pandemic. Anosmia, as well as dysgeusia, cannot be evaluated in patients of eTSS for a while after surgery. We report a case of an infundibular epidermoid cyst with post-eTSS Mollaret's meningitis (MM). The post-eTSS MM caused vasopressin-analogue-resistant polyuria (VARP) in synchronization with PPP. A 59-year-old man experiencing recurrent headaches and irregular bitemporal hemianopsia over three months was diagnosed with a suprasellar tumor. The suprasellar tumor was an infundibular cyst from the infundibular recess to the posterior lobe of the pituitary, which was gross-totally resected including the neurohypophysis via an extended eTSS. Since awakening from general anesthesia after the gross total resection (GTR) of the tumor, the patient continuously had suffered from headache until the 13^th postoperative day (POD13). The patient took analgesics once a day before the surgery and three times a day after the surgery until POD11. Pyrexia (37.5–39.5 degree Celsius) in synchronization with nonnephrogenic VARP remitted on POD18. Intravenous antibiotics had little effect on changes of pyrexia. Serum procalcitonin values (reference range <0.5 ng/mL) are 0.07 ng/mL on POD12 and 0.06 ng/mL on POD18. His polyuria came to react with sublingual desmopressin after alleviation of pyrexia. He left the hospital under hormone replacement therapy without newly added neurological sequelae other than hypopituitarism. After GTR of an infundibular epidermoid cyst, based on values of serum procalcitonin, post-eTSS MM can be distinguished from infection and can be treated with symptomatic treatments. The postoperative transient nonnephrogenic VARP that differs from usual central diabetes insipidus can react with sublingual desmopressin after alleviation of PPP in the clinical course of post-eTSS MM. An infundibular epidermoid cyst should be sufficiently resected in one sitting to minimize comorbidities, its recurrence, or postoperative MM to the utmost.

Neurogenic fever due to injury of the hypothalamus in a stroke patient: Case report

RATIONALE

Neurogenic fever is a non-infectious source of fever in a patient with brain injury, especially hypothalamic injury. We report on a stroke patient with neurogenic fever due to injury of hypothalamus, demonstrated by using diffusion tensor imaging (DTI).

PATIENT CONCERNS

A 28-year-old male patient was admitted to the rehabilitation department of university hospital at 30 months after onset. Brain MRI showed leukomalactic lesions in hypothalamus, bilateral medial temporal lobe, and bilateral basal ganglia. He showed intermittent high body temperature (maximum:39.5°C, range:38.5-39.2°C), but did not show any infection signs upon physical examination or after assessing his white blood cell count and inflammatory enzyme levels such as erythrocyte sedimentation rate and C-reactive protein. In addition, 8 age-matched normal (control) subjects (4 male, mean age: 26.6 years, range: 21-29years) were enrolled in the study.

DIAGNOSIS

Intraventricular hemorrhage and intracerebral hemorrhage in the left basal ganglia.

INTERVENTIONS

He underwent extraventricular drainage and ventriculoperitoneal shunting for hydrocephalus.

OUTCOMES

DTI was performed at 30 months after onset, fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values were obtained for hypothalamus. The FA and ADC values of patient were lower and higher, respectively, by more than two standard deviations from control values. Injury of hypothalamus was demonstrated in a stroke patient with neurogenic fever.

LESSIONS

Our results suggest that evaluation of hypothalamus using DTI would be helpful in patients show unexplained fever following brain injury.

In a model of SAH-induced neurogenic fever, BAT thermogenesis is mediated by erythrocytes and blocked by agonism of adenosine A1 receptors

Neurogenic fever (NF) after subarachnoid hemorrhage (SAH) is a major cause of morbidity that is associated with poor outcomes and prolonged stay in the neurointensive care unit (NICU). Though SAH is a much more common cause of fever than sepsis in the NICU, it is often a diagnosis of exclusion, requiring significant effort to rule out an infectious source. NF does not respond to standard anti-pyretic medications such as COX inhibitors, and lack of good medical therapy has led to the introduction of external cooling systems that have their own associated problems. In a rodent model of SAH, we measured the effects of injecting whole blood, blood plasma, or erythrocytes on the sympathetic nerve activity to brown adipose tissue and on febrile thermogenesis. We demonstrate that following SAH the acute activation of brown adipose tissue leading to NF, is not dependent on PGE₂, that subarachnoid space injection of whole blood or erythrocytes, but not plasma alone, is sufficient to trigger brown adipose tissue thermogenesis, and that activation of adenosine A1 receptors in the CNS can block the brown adipose tissue thermogenic component contributing to NF after SAH. These findings point to a distinct thermogenic mechanism for generating NF, compared to those due to infectious causes, and will hopefully lead to new therapies.

Evidence-practice gaps in initial neuro-protective nursing care: A mixed methods study of Thai patients with moderate or severe traumatic brain injury

AIMS

This paper aims to identify the frequency and nature of evidence-practice gaps in the initial neuro-protective nursing care of patients with moderate or severe traumatic brain injury provided by Thai trauma nurses.

BACKGROUND

Little is known about how Thai trauma nurses use evidence-based practice when providing initial neuro-protective nursing care to patients with moderate or severe traumatic brain injury.

DESIGN

A mixed methods design was used to conduct this study.

METHODS

Data were collected from January to March 2017 using observations and audits of the clinical care of 22 patients by 35 nurses during the first 4 h of admission to trauma ward. The study site was a regional hospital in Southern Thailand.

RESULTS

The major evidence-practice gaps identified were related to oxygen and carbon dioxide monitoring and targets, mean arterial pressure and systolic blood pressure targets and management of increased intracranial pressure through patient positioning and pain and agitation management.

CONCLUSION

There were evidence-practice gaps in initial neuro-protective nursing care provided by Thai trauma nurses that need to be addressed to improve the safety and quality of care for Thai patients with moderate or severe traumatic brain injury.

Uncontrolled central hyperthermia by standard dose of bromocriptine: A case report

BACKGROUND

Some patients present to the intensive care unit due to noninfectious pathologies resulting in fever, especially acute neurological injuries, including brain trauma and intracranial haemorrhage. The cause has been identified to be central hyperthermia characterized by a high core temperature and a poor response to antipyretics and antibiotics. However, no proper guidelines on how to treat central hyperthermia have been developed for clinical practice.

CASE SUMMARY

A 63-year-old woman was transferred to our hospital due to injury after a traffic accident. Eight hours after admission, her pupils enlarged bilaterally from 2.5 mm to 4.0 mm. She developed severe coma and underwent decompressive craniectomy. She was diagnosed with central hyperthermia after surgery and was prescribed bromocriptine. The standard dose of bromocriptine could not control her hyperpyrexia, and we prescribed 30 mg a day to control her temperature.

CONCLUSION

Bromocriptine may be effective in controlling central hyperthermia and have a dosage effect.

Temperature management in acute brain injury: A systematic review of clinical evidence

Temperature alterations in neurocritical care settings are common and have a striking effect on brain metabolism leading to or exacerbating neuronal injury. Hyperthermia worsens acute brain injury (ABI) patients outcome. However conclusive evidence linking control of temperature to improved outcome is still lacking. This review article report an update -results from clinical studies published between March 2006 and March 2020- on the relationship between hyperthermia or Target Temperature Management and functional outcome or mortality in ABI patients.

MATERIALS AND METHODS

A systematic search of articles in PubMed and EMBASE database was accomplished. Only complete studies, published in English in peer-reviewed journals were included.

RESULTS

A total of 63 articles into 5 subchapters are presented: acute ischemic stroke (17), subarachnoid hemorrhage (14), brain trauma (14), intracranial hemorrhage (8), and mixed acute brain injury (10). This evidence confirm and extend the negative impact of hyperthermia in ABI patients on worse functional outcome and higher mortality. In particular "early hyperthermia" in AIS patients seems to have a protective role have as promoting factor of clot lysis but no conclusive evidence is available. Normothermic TTM seems to have a positive effect on TBI patients in a reduced mortality rate compared to hypothermic TTM.

CONCLUSIONS

Hyperthermia in ABI patients is associated with worse functional outcome and higher mortality. The use of normothermic TTM has an established indication only in TBI; further studies are needed to define the role and the indications of normothermic TTM in ABI patients.

Seizures at the onset of aneurysmal SAH: epiphenomenon or valuable predictor?

Objective

Seizures at the onset (SAO) of aneurysmal subarachnoid hemorrhage (aSAH) occur in up to one of every five cases. To date, there is no consensus on causal background and clinical value of these early bleeding-related seizures. This study aimed to analyze the predictors and the impact of SAO in aSAH.

Methods

All aSAH patients from the institutional observational cohort (01/2003–06/2016) were retrospectively reviewed. Patients’ charts and emergency protocols from first responders were screened for the occurrence of seizures in the first 24 h after aSAH. Patients’ baseline characteristics and occurrence of post-hemorrhagic complications were analyzed. Outcome endpoints included in-hospital mortality and poor outcome at 6-month follow-up (modified Rankin Scale > 3).

Results

Of 984 patients included in the final analysis, SAO occurred in 93 cases (9.5%) and were independently associated with younger age (< 51 years, p < 0.001), WFNS grade ≥ 4 (p < 0.001), aneurysm characteristics (location at the proximal branch of the anterior cerebral artery [p = 0.037] and irregular sac [p = 0.019]) and admission body temperature > 38.3 ℃ (p = 0.008). There was an association between SAO and early complications (early infarcts [p = 0.004] and primary decompressive craniectomy [p = 0.024]). Only in the subgroup analysis restricted to the younger individuals, SAO independently predicted poor outcome of aSAH (p = 0.002).

Significance

Onset seizures following aSAH are rare and most likely related to the severity of early brain injury. Particularly, younger individuals are not only at higher risk for SAO, but are also prone to poor outcome in case of aSAH accompanied with SAO.

Trial registration number

German clinical trial registry (DRKS, unique identifier: DRKS00008749, 06/09/2015)

Metabolomics coupled with integrative pharmacology reveals the therapeutic effect of l-borneolum against cerebral ischaemia in rats

Objectives

This study aimed to investigate metabolic biomarker changes and related metabolic pathways before and after treatment with l-borneolum in cerebral ischaemic rats.

Methods

Rats were subjected to pMCAO surgery. The Zea-Longa scoring method was used to evaluate neurological deficits. TTC staining was used to observe cerebral infarction. HE staining was used to observe the pathological changes in brain tissue. The metabolomics method was used to analyse the changes in metabolism.

Results

The pharmacology changes of the H-B group were significantly different from those of the vehicle group. Moreover, according to the metabolomics method, identification of potential biomarkers in cerebral ischaemia treatment showed that the levels of l-valine and l-arginine were increased while the levels of N-succinyl-L,L-2,6-diaminopimelate and LysoPC (18 : 1(9Z)) were reduced, which were related to energy metabolism. Simultaneously, thermogenesis and bile secretion levels were inhibited by l-borneolum. Furthermore, elevated level of methotrexate might be related to an anti-inflammatory effect.

Conclusions

The therapeutic effect of l-borneolum on cerebral ischaemia might be associated with the regulation of energy metabolism, thermogenesis and bile secretion. These metabolic changes and the core target changes, as well as the metabolic-target pathway network, help to elucidate the mechanisms governing the effect of l-borneolum on cerebral ischaemia.

Continuous intravenous low-dose diclofenac sodium to control a central fever after ischemic stroke in the intensive care unit: a case report and review of the literature

Introduction

Elevation in body temperature within the first 24 hours of ischemic stroke is fairly common and known to be associated with worse outcomes. Only after thoroughly ruling out infection and the noninfectious etiologies and in the appropriate clinical setting should the diagnosis of central fever be made. Acetaminophen and nonsteroidal anti-inflammatory drugs are typical therapeutic options. External cooling is frequently used when pharmacologic interventions are inadequate. However, reports have suggested that neurogenic fevers are somewhat resistant to traditional pharmacologic therapies.

Case presentation

We describe a case of a Caucasian patient with central fever after ischemic stroke not responsive to acetaminophen administration and external cooling. After an initial bolus of diclofenac sodium (0.2 mg/kg in 100 ml of saline solution for 30 minutes), a continuous infusion (75 mg in 50 ml of saline solution) was started. After 5 days of treatment, the patient’s body temperature was below 37.5 °C, and the diclofenac sodium infusion was stopped.

Conclusions

We observed that a low-dose diclofenac sodium infusion was effective in treating fever without systemic side effects. This treatment may be suggested as an alternative to conventional antipyretic drugs, but additional clinical trials are required.

Non-infectious Fever After Acute Spinal Cord Injury in the Intensive Care Unit

OBJECTIVE

The aim of the present study is to evaluate the frequency, etiology, risk factors and clinical outcomes in acute traumatic SCI patients who develop fever and to evaluate the relationship between fever and mortality.

DESIGN

Retrospective data were collected between January 2007 and August 2016 from patients diagnosed with persistent fever from SCI cases observed in the ICU.

PARTICIPANTS

Among 5370 intensive care patients, 435 SCI patients were evaluated for the presence of fever. A total of 52 patients meeting the criteria were evaluated.

OUTCOME MEASURES

Fever characteristics were evaluated by dividing the patients into two groups: infectious (group-1) and non-infectious (group-2) fever. Demographic and clinical data, ICU and hospital stay, and mortality were evaluated.

RESULTS

In the patients with noninfectious fever, mortality was significantly higher compared to the group with infectious fever (P < 0.001). Of 52 acute SCI cases, 25 (48.1%) had neurogenic fever that did not respond to treatment in intensive care follow-up, and 22 (88%) of these patients died. Maximal fever was 39.10 ± 0.64 °C in Group-1 and 40.22 ± 1.10 ° C in Group-2 (P = 0.001). There was a significant difference in the duration of ICU stay and hospital stay between the two groups (P = 0.005, P = 0.001, respectively), while there was no difference in the duration of mechanical ventilation between the groups (P = 0.544).

CONCLUSION

This study demonstrates that patients diagnosed with neurogenic fever following SCI had higher average body temperature and higher rates of mortality compared to patients diagnosed with infectious fever.

[Fever in the critically ill : To treat or not to treat]

Fever, arbitrarily defined as a core body temperature >38.3 °C, is present in 20-70 % of intensive care unit patients. Fever caused by infections is a physiologic reset of the thermostatic set-point and is associated with beneficial consequences, but may have negative sequelae with temperatures >39.5 °C. Fever of non-infectious and neurologic origin affects about 50 % of patients with elevated body temperature, presents as a pathologic loss of thermoregulation, and may be associated with untoward side effects at temperatures above 38.5-39.0 °C. Cooling can be achieved by physical and pharmacologic means. Evidence-based recommendations are not available. The indication for a cooling therapy can only be based on the physiologic reserve and the neurologic, hemodynamic, and respiratory state. The temperature should be lowered to the normothermic range. Hyperthermia syndromes require immediate physical cooling (and dantrolen when indicated).

Neurocognitive Function after Cardiac Surgery: From Phenotypes to Mechanisms

For half a century, it has been known that some patients experience neurocognitive dysfunction after cardiac surgery; however, defining its incidence, course, and causes remains challenging and controversial. Various terms have been used to describe neurocognitive dysfunction at different times after cardiac surgery, ranging from "postoperative delirium" to "postoperative cognitive dysfunction or decline." Delirium is a clinical diagnosis included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Postoperative cognitive dysfunction is not included in the DSM-5 and has been heterogeneously defined, though a recent international nomenclature effort has proposed standardized definitions for it. Here, the authors discuss pathophysiologic mechanisms that may underlie these complications, review the literature on methods to prevent them, and discuss novel approaches to understand their etiology that may lead to novel treatment strategies. Future studies should measure both delirium and postoperative cognitive dysfunction to help clarify the relationship between these important postoperative complications.

Targeted temperature management in patients with intracerebral haemorrhage, subarachnoid haemorrhage, or acute ischaemic stroke: consensus recommendations

BACKGROUND

A modified Delphi approach was used to identify a consensus on practical recommendations for the use of non-pharmacological targeted temperature management in patients with intracerebral haemorrhage, subarachnoid haemorrhage, or acute ischaemic stroke with non-infectious fever (assumed neurogenic fever).

METHODS

Nine experts in the management of neurogenic fever participated in the process, involving the completion of online questionnaires, face-to-face discussions, and summary reviews, to consolidate a consensus on targeted temperature management.

RESULTS

The panel's recommendations are based on a balance of existing evidence and practical considerations. With this in mind, they highlight the importance of managing neurogenic fever using a single protocol for targeted temperature management. Targeted temperature management should be initiated if the patient temperature increases above 37.5°C, once an appropriate workup for infection has been undertaken. This helps prevent prophylactic targeted temperature management use and ensures infection is addressed appropriately. When neurogenic fever is detected, targeted temperature management should be initiated rapidly if antipyretic agents fail to control the temperature within 1 h, and should then be maintained for as long as there is potential for secondary brain damage. The recommended target temperature for targeted temperature management is 36.5-37.5°C. The use of advanced targeted temperature management methods that enable continuous, or near continuous, temperature measurement and precise temperature control is recommended.

CONCLUSIONS

Given the limited heterogeneous evidence currently available on targeted temperature management use in patients with neurogenic fever and intracerebral haemorrhage, subarachnoid haemorrhage, or acute ischaemic stroke, a Delphi approach was appropriate to gather an expert consensus. To aid in the development of future investigations, the panel provides recommendations for data gathering.

Paradoxical undressing associated with subarachnoid hemorrhage in a non-hypothermia case?

Paradoxical undressing is a phenomenon characterizing some fatal hypothermia cases. The victims, despite low environmental temperatures, paradoxically remove their clothes due to a sudden feeling of warmth. In this report, we describe a case of suspected paradoxical undressing in a non-hypothermia case. The victim, a 51-year-old Caucasian man, was found dead wearing only sneakers and socks. All other clothing was found in his car. Postmortem investigations allowed the hypothesis of hypothermia to be ruled out and revealed the presence of a ruptured cerebral aneurysm that caused a subarachnoid hemorrhage, the latter responsible for the death. The absence of any elements suggesting a voluntary undressing or any third party's DNA profile or involvement along with the possibility that the subarachnoid hemorrhage might have determined a hypothalamic injury, somehow rendered conceivable the hypothesis of an inappropriate feeling of warmth due to hemorrhage-induced dysregulation of the hypothalamic temperature-regulating centers.

Neurogenic fever in a patient with a chordoid glioma

Chordoid gliomas are rare tumours. Despite being considered low-grade neoplasms, recent reviews have reported generally poor prognosis due to complications involving severe hypothalamic symptoms. We report a patient aged 30 years with chordoid glioma. What makes this case report interesting is the presence of neurogenic fever, which was already present before the final diagnosis of the brain tumour and also several months after the surgical removal. Since the patient underwent a subtotal resection of the tumour, it remains unclear whether the fever was due to hypothalamic dysfunction or remnants of the tumour. We also performed temperature logging with a continuous-monitoring recording device.