Paroxysmal Sympathetic Hyperactivity in Patients Victims of Traumatic Brain Injury: Literature Review

The present literature review aims to present the physiology of paroxysmal sympathetic hyperactivity (PSH) as well as its clinical course, conceptualizing them, and establishing its diagnosis and treatment. Paroxysmal sympathetic hyperactivity is a rare syndrome, which often presents after an acute traumatic brain injury. Characterized by a hyperactivity of the sympathetic nervous system, when diagnosed in its pure form, its symptomatologic presentation is through tachycardia, tachypnea, hyperthermia, hypertension, dystonia, and sialorrhea. The treatment of PSH is basically pharmacological, using central nervous system suppressors; however, the nonmedication approach is closely associated with a reduction in external stimuli, such as visual and auditory stimuli. Mismanagement can lead to the development of serious cardiovascular and diencephalic complications, and the need for neurosurgeons and neurointensivists to know about PSH is evident in order to provide a fast and accurate treatment of this syndrome.

Cardiovascular autonomic neuropathy in type 2 diabetic patients

SUMMARY Diabetes is one of the most common chronic pathologies around the world, involving treatment with general clinicians, endocrinologists, cardiologists, ophthalmologists, nephrologists and a multidisciplinary team. Patients with type 2 Diabetes Mellitus (T2DM) can be affected by cardiac autonomic neuropathy, leading to increased mortality and morbidity. In this review, we will present current concepts, clinical features, diagnosis, prognosis, and possible treatment. New drugs recently developed to reduce glycemic level presented a pleiotropic effect of reducing sudden death, suggesting a potential use in patients at risk.

RESUMO Diabetes é uma das mais frequentes patologias crônicas em todo o mundo, cujo tratamento envolve uma equipe multidisciplinar, médicos generalistas, endocrinologistas, cardiologistas, nefrologistas e oftalmologistas. Pacientes com diabetes mellitus tipo 2 (DMT2) podem apresentar neuropatia autonômica cardíaca (NAC), levando a aumento de mortalidade e morbidade. Nesta revisão, apresentaremos atuais conceitos, características clínicas, diagnóstico, prognóstico e possíveis tratamentos. Novas drogas recentemente desenvolvidas para redução de níveis glicêmicos apresentaram efeito pleiotrópico de redução de morte súbita, sugerindo um potencial uso neste perfil de pacientes.

Relação entre a regulação autonômica cardíaca e mecanismos auditivos: importância para o crescimento e desenvolvimento / Relationship between cardiac autonomic regulation and auditory mechanisms: importance for growth and development

A literatura já demonstrou que a estimulação auditiva por meio de música influencia o sistema cardiovascular. Neste estudo, foi realizada uma revisão da literatura, a fim de investigar a relação entre os mecanismos auditivos e a regulação autonômica cardíaca. Os estudos selecionados indicaram forte correlação entre a intensidade do ruído e o equilíbrio simpatovagal. Além disso, foi relatado que a terapia com música melhorou a variabilidade da frequência cardíaca em pacientes com câncer de mama tratados com antraciclinas. Postula-se que a dopamina liberada no sistema estriatal, induzida por canções alegres, está envolvida na regulação autonômica. Estudos posteriores sãonecessários para adicionar novos elementos na literatura, para melhorar a novas terapias e para o tratar doenças cardiovasculares.

Tormenta simpática paroxística como manifestación de daño axonal difuso postraumatismo encefalocraneano / Paroxysmal sympathetic storm as a manifestation of diffuse axonal damage

Presentamos el caso de un hombre de 24 años que, secundario a un accidente de tránsito, presentó un traumatismo encefalocraneano grave con daño axonal difuso. Luego de un mes de evolución en la unidad de cuidados intensivos comenzó a presentar episodios súbitos de hipertensión, taquicardia, diaforesis, hipertermia, descerebración y dilatación pupilar, todo lo anterior con resolución espontánea en el curso de minutos. Estas crisis se repetían varias veces en el día. Se llegó al diagnóstico de un cuadro denominado Tormenta Simpática Paroxística que puede presentarse muy ocasionalmente como consecuencia de una lesión cerebral grave, especialmente el daño axonal postraumático. En este trastorno prima un desbalance simpático/parasimpático, lo que podría deberse a una pérdida del control cortical. El paciente fue tratado con opiáceos y betabloqueo con una respuesta satisfactoria, logrando disminuir significativamente sus episodios de tormentas simpáticas paroxísticas. En suma, nos parece importante comunicar esta experiencia dado la alta prevalencia de pacientes con trauma cerebral en nuestras Unidades de Pacientes Críticos. A pesar de que ni su diagnóstico ni tratamiento mejoran el pronóstico, su reconocimiento ahorra estudios innecesarios y permite iniciar una terapia sencilla que lleva al control precoz de la sintomatología.

A 24-year-old man suffered a traumatic brain injury due to a car accident. After one month of hospitalization in intensive care unit, he experimented episodic crisis of hypertension, tachycardia, hyperhidrosis, hypertermia, extensor posturing and pupil dilatation. This events presented in average 10 times per day. We reached to the diagnosis of Paroxysmal Sympathetic Storm. This is a subtype of dysautonomy which is present occasionally after a brain traumatic injury. The main mechanism of this brain dysfunction is a disassociation between the sympathetic and parasympathetic nervous systems due to cortical control loss. The patient was treated with morphine and labetalol and he experimented an excellent response, reducing his episodes of paroxysmal sympathetic storm by 80 percent. The aim of this review is to communicate this entity because a prompt and accurate diagnosis could minimize unnecessary studies and treatments.

Hiperreflexia autonômica simpática: revisäo da literatura / Simpathetic autonomic hyperreflexia: a review of literature

Os autores apresentam uma revisao sobre a alta incidência de hiperreflexia autonômica simpática que ocorre em pacientes vitimas de lesoes medulares cervicais e torácicas altas, e alertam para a grande importância do diagnóstico precoce, prevençao e tratamento desta síndrome.

Diabetic heart disease--current problems and their management.

Diabetic heart disease (DHD) is one of the most important contemporary management problems confronting the entire diabetic management team. DHD is multifactorial and multifaceted. The three major problems are: coronary artery disease (CAD), autonomic cardiac denervation and a specific heart muscle disease in diabetes (diabetic cardiomyopathy). Various other ancillary problems include obesity, hypertension, lipid aberrations and rheological alterations etc. CAD and diabetes mellitus (DM) have a greater association; the disease is more severe, sets in early and has many atypical features including painless, silent onset, delayed arrival at intensive coronary care unit, increased incidence of pump failure and arrhythmias and high case fatality rate. Autonomic cardiac denervation is an important and a common companion of diabetic peripheral neuropathy and has serious repercussions in DHD. Simple, sensitive screening tests may identify such a group so as to exercise caution in management. Various clinical (non-invasive, invasive and autopsy) and experimental studies provide evidence for the existence of a specific diabetic heart muscle disease comprising of small vessel disease and metabolic aberrations. Recent advances in literature and our own experience are reviewed. The practical management aspects of each facet, such as maintenance of high index of suspicion, early diagnosis and referral, close monitoring, role of rigid blood glucose control and specific role of each member of the diabetic team is outlined. The possible preventative strategies are discussed.