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Optimal Treatment of Dysautonomia

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Controversies in Severe Traumatic Brain Injury Management

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Abstract

Autonomic dysfunction following traumatic brain injury is a frequent complication that occasionally persists as a clinical syndrome now known as paroxysmal sympathetic hyperactivity (PSH) in as many as 10% of TBI patients. While the pathophysiology of PSH is relatively unknown, it is believed to be a result of a loss of inhibitory modulation on nociceptive spinal afferents due to brain injury, leading to a disproportionate sympathetic response. Clinical features of this syndrome include tachycardia, hypertension, hyperhidrosis, hyperthermia, and tachypnea as well as muscle dystonia and posturing. Symptoms of PSH are typically managed with pharmacologic agents such as beta-blockers, morphine, gabapentin, bromocriptine, and, rarely, intrathecal baclofen therapy. While PSH is thought to result in detrimental short-term outcomes, it is not clear to what extent these patients suffer long-term consequences. Nevertheless, PSH is an important complication of TBI, and recognition of this syndrome is necessary for managing autonomic dysfunction in the post-TBI patient.

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References

  1. 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. 2008;8(2):293–300.

    Article  Google Scholar 

  2. Perkes I, Baguley IJ, Nott MT, Menon DK. A review of paroxysmal sympathetic hyperactivity after acquired brain injury. Ann Neurol. 2010;68(2):126–35.

    Article  Google Scholar 

  3. Baguley IJ. Nomenclature of “paroxysmal sympathetic storms”. Mayo Clin Proc. 1999;74(1):105.

    Article  CAS  Google Scholar 

  4. Baguley IJ, Perkes IE, Fernandez-Ortega J-F, Rabinstein AA, Dolce G, Hendricks HT, et al. Paroxysmal sympathetic hyperactivity after acquired brain injury: consensus on conceptual definition, nomenclature, and diagnostic criteria. J Neurotrauma. 2014;31(17):1515–20.

    Article  Google Scholar 

  5. Baguley IJ, Nicholls JL, Felmingham KL, Crooks J, Gurka JA, Wade LD. Dysautonomia after traumatic brain injury: a forgotten syndrome? J Neurol Neurosurg Psychiatry. 1999;67(1):39–43.

    Article  CAS  Google Scholar 

  6. Baguley IJ, Nott MT, Slewa-Younan S, Heriseanu RE, Perkes IE. Diagnosing dysautonomia after acute traumatic brain injury: evidence for overresponsiveness to afferent stimuli. Arch Phys Med Rehabil. 2009;90(4):580–6.

    Article  Google Scholar 

  7. Goddeau RP, Silverman SB, Sims JR. Dexmedetomidine for the treatment of paroxysmal autonomic instability with dystonia. Neurocrit Care. 2007;7(3):217–20.

    Article  CAS  Google Scholar 

  8. Blackman JA, Patrick PD, Buck ML, Rust RS. Paroxysmal autonomic instability with dystonia after brain injury. Arch Neurol. 2004;61(3):321–8.

    Article  Google Scholar 

  9. Baguley IJ, Heriseanu RE, Nott MT, Chapman J, Sandanam J. Dysautonomia after severe traumatic brain injury: evidence of persisting overresponsiveness to afferent stimuli. Am J Phys Med Rehabil. 2009;88(8):615–22.

    Article  Google Scholar 

  10. 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. 2007;21(11):1175–81.

    Article  Google Scholar 

  11. Hendricks HT, Heeren AH, Vos PE. Dysautonomia after severe traumatic brain injury. Eur J Neurol. 2010;17(9):1172–7.

    Article  CAS  Google Scholar 

  12. Rabinstein AA. Paroxysmal sympathetic hyperactivity in the neurological intensive care unit. Neurol Res. 2007;29(7):680–2.

    Article  Google Scholar 

  13. Rutland-Brown W, Langlois JA, Thomas KE, Xi YL. Incidence of traumatic brain injury in the United States, 2003. J Head Trauma Rehabil. 2006;21(6):544–8.

    Article  Google Scholar 

  14. Penfield W. Diencephalic autonomic epilepsy. Arch Neurol Psychiatr. 1929;22(2):358–74.

    Article  Google Scholar 

  15. Do D, Sheen VL, Bromfield E. Treatment of paroxysmal sympathetic storm with labetalol. J Neurol Neurosurg Psychiatry. 2000;69(6):832–3.

    Article  CAS  Google Scholar 

  16. Boeve BF, Wijdicks EF, Benarroch EE, Schmidt KD. Paroxysmal sympathetic storms (“diencephalic seizures”) after severe diffuse axonal head injury. Mayo Clin Proc. 1998;73(2):148–52.

    Article  CAS  Google Scholar 

  17. Bullard DE. Diencephalic seizures: responsiveness to bromocriptine and morphine. Ann Neurol. 1987;21(6):609–11.

    Article  CAS  Google Scholar 

  18. Clifton GL, Ziegler MG, Grossman RG. Circulating catecholamines and sympathetic activity after head injury. Neurosurgery. 1981;8(1):10–4.

    Article  CAS  Google Scholar 

  19. Grunsfeld A, Fletcher JJ, Nathan BR. Cardiopulmonary complications of brain injury. Curr Neurol Neurosci Rep. 2005;5(6):488–93.

    Article  Google Scholar 

  20. Woiciechowsky C, Asadullah K, Nestler D, Eberhardt B, Platzer C, Schöning B, et al. Sympathetic activation triggers systemic interleukin-10 release in immunodepression induced by brain injury. Nat Med. 1998;4(7):808–13.

    Article  CAS  Google Scholar 

  21. Mehta NM, Bechard LJ, Leavitt K, Duggan C. Severe weight loss and hypermetabolic paroxysmal dysautonomia following hypoxic ischemic brain injury: the role of indirect calorimetry in the intensive care unit. JPEN J Parenter Enteral Nutr. 2008;32(3):281–4.

    Article  Google Scholar 

  22. Baguley IJ, Heriseanu RE, Gurka JA, Nordenbo A, Cameron ID. Gabapentin in the management of dysautonomia following severe traumatic brain injury: a case series. J Neurol Neurosurg Psychiatry. 2007;78(5):539–41.

    Article  Google Scholar 

  23. Soukup J, Zauner A, Doppenberg EMR, Menzel M, Gilman C, Young HF, et al. The importance of brain temperature in patients after severe head injury: relationship to intracranial pressure, cerebral perfusion pressure, cerebral blood flow, and outcome. J Neurotrauma. 2002;19(5):559–71.

    Article  Google Scholar 

  24. Hoarau X, Richer E, Dehail P, Cuny E. A 10-year follow-up study of patients with severe traumatic brain injury and dysautonomia treated with intrathecal baclofen therapy. Brain Inj. 2012;26(7–8):927–40.

    Article  Google Scholar 

  25. Perkes IE, Menon DK, Nott MT, Baguley IJ. Paroxysmal sympathetic hyperactivity after acquired brain injury: a review of diagnostic criteria. Brain Inj. 2011;25(10):925–32.

    Article  Google Scholar 

  26. Fernández-Ortega JF, Prieto-Palomino MA, Muñoz-López A, Lebron-Gallardo M, Cabrera-Ortiz H, Quesada-García G. Prognostic influence and computed tomography findings in dysautonomic crises after traumatic brain injury. J Trauma. 2006;61(5):1129–33.

    Article  Google Scholar 

  27. Dolce G, Quintieri M, Leto E, Milano M, Pileggi A, Lagani V, et al. Dysautonomia and clinical outcome in vegetative state. J Neurotrauma. 2008:4.

    Google Scholar 

  28. Hendricks HT, Geurts ACH, van Ginneken BC, Heeren AJ, Vos PE. Brain injury severity and autonomic dysregulation accurately predict heterotopic ossification in patients with traumatic brain injury. Clin Rehabil. 2007;21(6):545–53.

    Article  Google Scholar 

  29. Bilotta F, Branca G, Lam A, Cuzzone V, Doronzio A, Rosa G. Endotracheal lidocaine in preventing endotracheal suctioning-induced changes in cerebral hemodynamics in patients with severe head trauma. Neurocrit Care. 2008;8(2):241–6.

    Article  CAS  Google Scholar 

  30. Pattoneri P, Tirabassi G, Pelá G, Astorri E, Mazzucchi A, Borghetti A. Circadian blood pressure and heart rate changes in patients in a persistent vegetative state after traumatic brain injury. J Clin Hypertens Greenwich Conn. 2005;7(12):734–9.

    Article  Google Scholar 

  31. Kanjwal K, Karabin B, Kanjwal Y, Grubb BP. Autonomic dysfunction presenting as postural tachycardia syndrome following traumatic brain injury. Cardiol J. 2010;17(5):482–7.

    PubMed  Google Scholar 

  32. Cuny E, Richer E, Castel JP. Dysautonomia syndrome in the acute recovery phase after traumatic brain injury: relief with intrathecal baclofen therapy. Brain Inj. 2001;15(10):917–25.

    Article  CAS  Google Scholar 

  33. Laxe S, Terré R, León D, Bernabeu M. How does dysautonomia influence the outcome of traumatic brain injured patients admitted in a neurorehabilitation unit? Brain Inj. 2013;27(12):1383–7.

    Article  Google Scholar 

  34. Baguley IJ, Heriseanu RE, Felmingham KL, Cameron ID. Dysautonomia and heart rate variability following severe traumatic brain injury. Brain Inj. 2006;20(4):437–44.

    Article  Google Scholar 

  35. Gordon WA, Zafonte R, Cicerone K, Cantor J, Brown M, Lombard L, et al. Traumatic brain injury rehabilitation: state of the science. Am J Phys Med Rehabil. 2006;85(4):343–82.

    Article  Google Scholar 

  36. Schroeppel TJ, Fischer PE, Zarzaur BL, Magnotti LJ, Clement LP, Fabian TC, et al. Beta-adrenergic blockade and traumatic brain injury: protective? J Trauma. 2010;69(4):776–82.

    Article  CAS  Google Scholar 

  37. Arbabi S, Ahrns KS, Wahl WL, Hemmila MR, Wang SC, Brandt M-M, et al. Beta-blocker use is associated with improved outcomes in adult burn patients. J Trauma. 2004;56(2):265–269-271.

    Article  CAS  Google Scholar 

  38. Schroeppel TJ, Sharpe JP, Magnotti LJ, Weinberg JA, Clement LP, Croce MA, et al. Traumatic brain injury and β-blockers: not all drugs are created equal. J Trauma Acute Care Surg. 2014;76(2):504–9. discussion 509

    Article  CAS  Google Scholar 

  39. Robertson CS, Clifton GL, Taylor AA, Grossman RG. Treatment of hypertension associated with head injury. J Neurosurg. 1983;59(3):455–60.

    Article  CAS  Google Scholar 

  40. Chioléro RL, Breitenstein E, Thorin D, Christin L, de Tribolet N, Freeman J, et al. Effects of propranolol on resting metabolic rate after severe head injury. Crit Care Med. 1989;17(4):328–34.

    Article  Google Scholar 

  41. Rossitch E, Bullard DE. The autonomic dysfunction syndrome: aetiology and treatment. Br J Neurosurg. 1988;2(4):471–8.

    Article  Google Scholar 

  42. Ivanhoe CB, Tilton AH, Francisco GE. Intrathecal baclofen therapy for spastic hypertonia. Phys Med Rehabil Clin N Am. 2001;12(4):923–38. viii–ix

    Article  CAS  Google Scholar 

  43. Baguley IJ, Bailey KM, Slewa-Younan S. Prolonged anti-spasticity effects of bolus intrathecal baclofen. Brain Inj. 2005;19(7):545–8.

    Article  CAS  Google Scholar 

  44. Becker R, Benes L, Sure U, Hellwig D, Bertalanffy H. Intrathecal baclofen alleviates autonomic dysfunction in severe brain injury. J Clin Neurosci. 2000;7(4):316–9.

    Article  CAS  Google Scholar 

  45. François B, Vacher P, Roustan J, Salle JY, Vidal J, Moreau JJ, et al. Intrathecal baclofen after traumatic brain injury: early treatment using a new technique to prevent spasticity. J Trauma. 2001;50(1):158–61.

    Article  Google Scholar 

  46. Payen D, Quintin L, Plaisance P, Chiron B, Lhoste F. Head injury: clonidine decreases plasma catecholamines. Crit Care Med. 1990;18(4):392–5.

    Article  CAS  Google Scholar 

  47. Russo RN, O’Flaherty S. Bromocriptine for the management of autonomic dysfunction after severe traumatic brain injury. J Paediatr Child Health. 2000;36(3):283–5.

    Article  CAS  Google Scholar 

  48. Heffernan DS, Inaba K, Arbabi S, Cotton BA. Sympathetic hyperactivity after traumatic brain injury and the role of beta-blocker therapy. J Trauma. 2010;69(6):1602–9.

    Article  Google Scholar 

  49. Baguley IJ, Cameron ID, Green AM, Slewa-Younan S, Marosszeky JE, Gurka JA. Pharmacological management of dysautonomia following traumatic brain injury. Brain Inj. 2004;18(5):409–17.

    Article  Google Scholar 

  50. Green LB, Nelson VS. Death after acute withdrawal of intrathecal baclofen: case report and literature review. Arch Phys Med Rehabil. 1999;80(12):1600–4.

    Article  CAS  Google Scholar 

  51. Hinson HE, Sheth KN. Manifestations of the hyperadrenergic state after acute brain injury. Curr Opin Crit Care. 2012;18(2):139–45.

    Article  Google Scholar 

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Authors and Affiliations

  1. Department of Neurosurgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA

    Gabriel N. Friedman BA

  2. Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA, USA

    Ziev B. Moses MD, Ian Tafel MD & William B. Gormley MD, MPH, MBA

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  1. Gabriel N. Friedman BA
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  2. Ziev B. Moses MD
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  3. Ian Tafel MD
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  4. William B. Gormley MD, MPH, MBA
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Correspondence to William B. Gormley MD, MPH, MBA .

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Editors and Affiliations

  1. Department of Neurosurgery, Penn State University Milton S. Hershey Medical Center, Hershey, PA, USA

    Shelly D. Timmons

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Friedman, G.N., Moses, Z.B., Tafel, I., Gormley, W.B. (2018). Optimal Treatment of Dysautonomia. In: Timmons, S. (eds) Controversies in Severe Traumatic Brain Injury Management. Springer, Cham. https://doi.org/10.1007/978-3-319-89477-5_14

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  • DOI: https://doi.org/10.1007/978-3-319-89477-5_14

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-89476-8

  • Online ISBN: 978-3-319-89477-5

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