1
|
Carozza RB, Mohanty D, Wolf MS, Martin EN, Anderson J, Pagano LM. Paroxysmal Sympathetic Hyperactivity: Development of a Pediatric Clinical Practice Guideline. Hosp Pediatr 2023; 13:e402-e410. [PMID: 37953681 DOI: 10.1542/hpeds.2023-007261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Affiliation(s)
| | | | | | | | - Jessica Anderson
- Department of Pharmacy, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee
| | | |
Collapse
|
2
|
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
|
3
|
Dolce G, Quintieri M, Leto E, Milano M, Pileggi A, Lagani V, Pignolo L. Dysautonomia and Clinical Outcome in Vegetative State. J Neurotrauma 2021; 38:1441-1444. [PMID: 18771395 DOI: 10.1089/neu.2008.0536] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
A dramatic disorder tentatively attributed to diencephalic-hypothalamic damage or dysfunction, dysautonomia, affects recovery from brain injury. Its incidence, correlation with etiology, and relevance as a predictor of outcome were retrospectively surveyed in 333 patients in vegetative state (VS) for more than 2 weeks at admission. Outcome was assessed according to the Glasgow Outcome Scale. Data were treated statistically by multi-variate analyses. Dysautonomia occurred in 26.1% of patients, with greater incidence among post-traumatic (31.9%) than non-traumatic (15.8%) patients. Outcome was worse among non-traumatic than post-traumatic patients irrespective of dysautonomia, and worst among non-traumatic patients with dysautonomia. Dysautonomia proved common among patients in VS (with incidence depending on etiology and age) and influenced the patients' outcome through mechanisms still to be defined, but conceivably mediated by diencephalic-hypothalamic unbalance.
Collapse
Affiliation(s)
| | | | | | | | | | - Vincenzo Lagani
- Department of Electronic, Informatics and Systemistics, University of Calabria, Cosenza, Italy
| | - Loris Pignolo
- Department of Electronic, Informatics and Systemistics, University of Calabria, Cosenza, Italy
| |
Collapse
|
4
|
Paroxysmal Sympathetic Hyperactivity: Diagnostic Criteria, Complications, and Treatment after Traumatic Brain Injury. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2018. [DOI: 10.1007/s40141-018-0175-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
|
5
|
Meyfroidt G, Baguley IJ, Menon DK. Paroxysmal sympathetic hyperactivity: the storm after acute brain injury. Lancet Neurol 2017; 16:721-729. [PMID: 28816118 DOI: 10.1016/s1474-4422(17)30259-4] [Citation(s) in RCA: 156] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 06/28/2017] [Accepted: 07/20/2017] [Indexed: 10/19/2022]
Abstract
A substantial minority of patients who survive an acquired brain injury develop a state of sympathetic hyperactivity that can persist for weeks or months, consisting of periodic episodes of increased heart rate and blood pressure, sweating, hyperthermia, and motor posturing, often in response to external stimuli. The unifying term for the syndrome-paroxysmal sympathetic hyperactivity (PSH)-and clear diagnostic criteria defined by expert consensus were only recently established. PSH has predominantly been described after traumatic brain injury (TBI), in which it is associated with worse outcomes. The pathophysiology of the condition is not completely understood, although most researchers consider it to be a disconnection syndrome with paroxysms driven by a loss of inhibitory control over excitatory autonomic centres. Although therapeutic strategies to alleviate sympathetic outbursts have been proposed, their effects on PSH are inconsistent between patients and their influence on outcome is unknown. Combinations of drugs are frequently used and are chosen on the basis of local custom, rather than on objective evidence. New rigorous tools for diagnosis could allow better characterisation of PSH to enable stratification of patients for future therapeutic trials.
Collapse
Affiliation(s)
- Geert Meyfroidt
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | | | - David K Menon
- Division of Anaesthesia, University of Cambridge, Cambridge, UK.
| |
Collapse
|
6
|
Meyer KS. Understanding paroxysmal sympathetic hyperactivity after traumatic brain injury. Surg Neurol Int 2014; 5:S490-2. [PMID: 25506508 PMCID: PMC4253044 DOI: 10.4103/2152-7806.144632] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 08/13/2014] [Indexed: 11/15/2022] Open
Abstract
Background: Paroxysmal sympathetic hyperactivity (PSH) is a condition occurring in a small percentage of patients with severe traumatic brain injury (TBI). It is characterized by a constellation of symptoms associated with excessive adrenergic output, including tachycardia, hypertension, tachypnea, and diaphoresis. Diagnosis is one of exclusion and, therefore, is often delayed. Treatment is aimed at minimizing triggers and pharmacologic management of symptoms. Methods: A literature review using medline and cinahl was conducted to identify articles related to PSH. Search terms included paroxysmal sympathetic hyperactivity, autonomic storming, diencephalic seizures, and sympathetic storming. Reference lists of pertinent articles were also reviewed and these additional papers were included. Results: The literature indicates that the understanding of PSH following TBI is in its infancy. The majority of information is based on small case series. The review revealed treatments that may be useful in treating PSH. Conclusions: Nurses play a critical role in the identification of at-risk patients, symptom complexes, and in the education of family. Early detection and treatment is likely to decrease overall morbidity and facilitate recovery. Further research is needed to establish screening tools and treatment algorithms for PSH.
Collapse
Affiliation(s)
- Kimberly S Meyer
- Kentucky One Healthcare, University of Louisville Hospital, 530 S Jackson St, Louisville, KY 40202, USA
| |
Collapse
|
7
|
Baguley IJ, Perkes IE, Fernandez-Ortega JF, Rabinstein AA, Dolce G, Hendricks HT. Paroxysmal Sympathetic Hyperactivity after Acquired Brain Injury: Consensus on Conceptual Definition, Nomenclature, and Diagnostic Criteria. J Neurotrauma 2014; 31:1515-20. [DOI: 10.1089/neu.2013.3301] [Citation(s) in RCA: 172] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ian J. Baguley
- Brain Injury Rehabilitation Service, Westmead Hospital, Wentworthville, New South Wales, Australia
| | - Iain E. Perkes
- Department of Psychiatry, Royal Prince Alfred Hospital, Sydney, Australia
| | | | | | - Giuliano Dolce
- S. Anna Institute—Research in Advanced Neurorehabilitation, Crotone, Italy
| | | | | |
Collapse
|
8
|
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]
|
9
|
Kirkham FJ, Haywood P, Kashyape P, Borbone J, Lording A, Pryde K, Cox M, Keslake J, Smith M, Cuthbertson L, Murugan V, Mackie S, Thomas NH, Whitney A, Forrest KM, Parker A, Forsyth R, Kipps CM. Movement disorder emergencies in childhood. Eur J Paediatr Neurol 2011; 15:390-404. [PMID: 21835657 DOI: 10.1016/j.ejpn.2011.04.005] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2011] [Accepted: 04/17/2011] [Indexed: 12/27/2022]
Abstract
The literature on paediatric acute-onset movement disorders is scattered. In a prospective cohort of 52 children (21 male; age range 2mo-15y), the commonest were chorea, dystonia, tremor, myoclonus, and Parkinsonism in descending order of frequency. In this series of mainly previously well children with cryptogenic acute movement disorders, three groups were recognised: (1) Psychogenic disorders (n = 12), typically >10 years of age, more likely to be female and to have tremor and myoclonus (2) Inflammatory or autoimmune disorders (n = 22), including N-methyl-d-aspartate receptor encephalitis, opsoclonus-myoclonus, Sydenham chorea, systemic lupus erythematosus, acute necrotizing encephalopathy (which may be autosomal dominant), and other encephalitides and (3) Non-inflammatory disorders (n = 18), including drug-induced movement disorder, post-pump chorea, metabolic, e.g. glutaric aciduria, and vascular disease, e.g. moyamoya. Other important non-inflammatory movement disorders, typically seen in symptomatic children with underlying aetiologies such as trauma, severe cerebral palsy, epileptic encephalopathy, Down syndrome and Rett syndrome, include dystonic posturing secondary to gastro-oesophageal reflux (Sandifer syndrome) and Paroxysmal Autonomic Instability with Dystonia (PAID) or autonomic 'storming'. Status dystonicus may present in children with known extrapyramidal disorders, such as cerebral palsy or during changes in management e.g. introduction or withdrawal of neuroleptic drugs or failure of intrathecal baclofen infusion; the main risk in terms of mortality is renal failure from rhabdomyolysis. Although the evidence base is weak, as many of the inflammatory/autoimmune conditions are treatable with steroids, immunoglobulin, plasmapheresis, or cyclophosphamide, it is important to make an early diagnosis where possible. Outcome in survivors is variable. Using illustrative case histories, this review draws attention to the practical difficulties in diagnosis and management of this important group of patients.
Collapse
Affiliation(s)
- F J Kirkham
- Southampton University Hospitals NHS Trust, UK.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Perkes IE, Menon DK, Nott MT, Baguley IJ. Paroxysmal sympathetic hyperactivity after acquired brain injury: A review of diagnostic criteria. Brain Inj 2011; 25:925-32. [DOI: 10.3109/02699052.2011.589797] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
11
|
Lv LQ, Hou LJ, Yu MK, Qi XQ, Chen HR, Chen JX, Hu GH, Luo C, Lu YC. Prognostic Influence and Magnetic Resonance Imaging Findings in Paroxysmal Sympathetic Hyperactivity after Severe Traumatic Brain Injury. J Neurotrauma 2010; 27:1945-50. [PMID: 21028988 DOI: 10.1089/neu.2010.1391] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Li-Quan Lv
- Department of Neurosurgery, Shanghai Institute of Neurosurgery, Shanghai Changzheng Hospital, Shanghai, China
| | - Li-Jun Hou
- Department of Neurosurgery, Shanghai Institute of Neurosurgery, Shanghai Changzheng Hospital, Shanghai, China
| | - Ming-Kun Yu
- Department of Neurosurgery, Shanghai Institute of Neurosurgery, Shanghai Changzheng Hospital, Shanghai, China
| | - Xiang-Qian Qi
- Department of Neurosurgery, Shanghai Institute of Neurosurgery, Shanghai Changzheng Hospital, Shanghai, China
| | - Huai-Rui Chen
- Department of Neurosurgery, Shanghai Institute of Neurosurgery, Shanghai Changzheng Hospital, Shanghai, China
| | - Ju-Xiang Chen
- Department of Neurosurgery, Shanghai Institute of Neurosurgery, Shanghai Changzheng Hospital, Shanghai, China
| | - Guo-Han Hu
- Department of Neurosurgery, Shanghai Institute of Neurosurgery, Shanghai Changzheng Hospital, Shanghai, China
| | - Chun Luo
- Department of Neurosurgery, Shanghai Institute of Neurosurgery, Shanghai Changzheng Hospital, Shanghai, China
| | - Yi-Cheng Lu
- Department of Neurosurgery, Shanghai Institute of Neurosurgery, Shanghai Changzheng Hospital, Shanghai, China
| |
Collapse
|
12
|
Perkes I, Baguley IJ, Nott MT, Menon DK. A review of paroxysmal sympathetic hyperactivity after acquired brain injury. Ann Neurol 2010; 68:126-35. [PMID: 20695005 DOI: 10.1002/ana.22066] [Citation(s) in RCA: 176] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Severe excessive autonomic overactivity occurs in a subgroup of people surviving acquired brain injury, the majority of whom show paroxysmal sympathetic and motor overactivity. Delayed recognition of paroxysmal sympathetic hyperactivity (PSH) after brain injury may increase morbidity and long-term disability. Despite its significant clinical impact, the scientific literature on this syndrome is confusing; there is no consensus on nomenclature, etiological information for diagnoses preceding the condition is poorly understood, and the evidence base underpinning our knowledge of the pathophysiology and management strategies is largely anecdotal. This systematic literature review identified 2 separate categories of paroxysmal autonomic overactivity, 1 characterized by relatively pure sympathetic overactivity and another group of disorders with mixed parasympathetic/sympathetic features. The PSH group comprised 349 reported cases, with 79.4% resulting from traumatic brain injury (TBI), 9.7% from hypoxia, and 5.4% from cerebrovascular accident. Although TBI is the dominant causative etiology, there was some suggestion that the true incidence of the condition is highest following cerebral hypoxia. In total, 31 different terms were identified for the condition. Although the most common term in the literature was dysautonomia, the consistency of sympathetic clinical features suggests that a more specific term should be used. The findings of this review suggest that PSH be adopted as a more clinically relevant and appropriate term. The review highlights major problems regarding conceptual definitions, diagnostic criteria, and nomenclature. Consensus on these issues is recommended as an essential basis for further research in the area.
Collapse
|
13
|
Baguley IJ, Slewa-Younan S, Heriseanu RE, Nott MT, Mudaliar Y, Nayyar V. The incidence of dysautonomia and its relationship with autonomic arousal following traumatic brain injury. Brain Inj 2009; 21:1175-81. [DOI: 10.1080/02699050701687375] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
14
|
Baguley IJ, Heriseanu RE, Cameron ID, Nott MT, Slewa-Younan S. A Critical Review of the Pathophysiology of Dysautonomia Following Traumatic Brain Injury. Neurocrit Care 2007; 8:293-300. [DOI: 10.1007/s12028-007-9021-3] [Citation(s) in RCA: 126] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|