脑损伤后发作性交感过度兴奋

脑损伤后发作性交感过度兴奋第1页，课件共25页，创作于2023年2月中重度脑损伤患者的临床表现中,常可见到一组发作性的高热、多汗、呼吸急促、心动过速、血压升高、瞳孔改变、烦躁并全身强直、阵挛等肌张力障碍等症候群。第2页，课件共25页，创作于2023年2月PerkesI,BaguleyIJ,NottMT,MenonDK.Areview1.ofparoxysmal

sympathetichyperactivityafteracquiredbraininjury.AnnNeurol

2010;68:126–135.tachycardia(>120beats/min),tachypnea(>30/min),systolichypertension(>160mmHg),hyper/hypothermia,excessivesweating,decerebration/decortication,increasedmuscletone,horripilation鸡皮疙瘩

and/orflushing皮肤发红

iscollectivelyreferredtoas“dysautonomia”or“paroxysmalsympathetichyperactivity”syndrome第3页，课件共25页，创作于2023年2月典型的体温血压图过山车第4页，课件共25页，创作于2023年2月发病率高低不一9.3–33%.KishnerS,AugustinJ,StrumS.Postheadinjuryautonomiccomplications.Lastupdated4October2006October4.Accessed18June2007.FearnsideMR,CookRJ,McDougallP,McNeilRJ.Thewestmeadheadinjuryprojectoutcomeinsevereheadinjury.Acomparativeanalysisofpre-hospital,clinicalandCTvariables.BritishJournalofNeurosurgery1993;7:267–279.Inthefirstpost-injuryweekinICU.Ofthewholesample,33%developedheartrates>120/minandrespiratoryrates>30/minand25%hadbloodpressure>160mmHgandtemperature>39Catsometimeinthefirstweek.第5页，课件共25页，创作于2023年2月LemkeDM.Sympatheticstormingafterseveretraumaticbrain

injury.CritCareNurse2007;27(1):30–7.onsetofdysautonomicparoxysmsandvariousafferentstimuli,bothnoxiousandnon-noxious.Suchstimulihaveincludedpain,endotrachealsuctioning,passivemovementssuchasturning,bathingandmusclestretching,constipation便秘

orakinkedcatheter导尿,emotionalstimuli,aswellasenvironmentalstimulisuchasloudnoises

第6页，课件共25页，创作于2023年2月LaxeS,TerréR,LeónD,BernabeuM.

Howdoesdysautonomiainfluencetheoutcomeoftraumaticbraininjuredpatients

admittedinaneurorehabilitationunit?BrainInj.2013;27(12):1383-7.AllpatientshadbeenreferredtotheS.AnnaInstitute–RANintheyears1998–2005forbeinginaVS/UWScondition.PSHoccurredin26.1%ofthem,withgreaterincidenceaftertraumaticthannon-traumaticbraininjury(31.9%vs15.8%).Outcomewasworsefollowingnon-traumaticbraindamageirrespectiveofPSHandworstamongnon-traumaticsubjectswithPSH.untreatedDysautonomiaincreasesmortalitythroughprolongedhyperthermia,excessivecatabolism分解代谢,highcatecholamine儿茶酚胺

levelsandspasticity/dystonia临床值得关注和重视！第7页，课件共25页，创作于2023年2月BaguleyIJ,HeriseanuRE,GurkaJA,NordenboA,CameronID.

GabapentininthemanagementofDysautonomiafollowing

severetraumaticbraininjury:acaseseries.JNeurolNeurosurg

Psychiatr2007;78(5):539–41itisnotpossibletocompletelyexcludeanepileptogenicaetiologyforallcasesofDysautonomiamultipleattemptstoeitheridentifyortreatepilepsyinDysautonomicpatientshaveproduced

negativeresults第8页，课件共25页，创作于2023年2月

常见原因脑外伤、肿瘤、脑积水、颅内出血、

蛛网膜下腔出血、缺氧性脑病,其中脑外伤是最常见的原因也有各种原因导致的缺氧性脑病第9页，课件共25页，创作于2023年2月

Dysautonomia临床涵盖多个综合征ThesesyndromesincludeNMS,SS,Parkinsonian-HyperpyrexiaSyndrome(PHS)intrathecalbaclofenwithdrawalAutonomicDysreflexiaMalignantCatatonia紧张症MalignantHyperthermiaStiffManSyndromeandIrukandjiSyndrome.第10页，课件共25页，创作于2023年2月

针对脑损伤后的症候群--命名创伤性脑损伤后自主神经功能障碍、自主神经功能障碍综合征、急性下丘脑功能不稳、下丘脑中脑功能失调综合征、间脑综合征、间脑发作、发作性自主神经或交感神经爆发、中枢热、高热伴持续性肌肉收缩第11页，课件共25页，创作于2023年2月

病因区别脑损伤后发作性自主神经功能障碍家族性遗传性自主神经功能障碍、病毒感染后自主神经功能障碍、Guillain-Barre综合征伴发的自主神经功能障碍、脊髓损伤后的自主神经功能障碍第12页，课件共25页，创作于2023年2月BlackmanJA,PatrickPD,BuckML,RustJr.RS.Paroxysmalautonomicinstabilitywithdystoniaafterbraininjury.

ArchivesofNeurology2004;61:321–328.ParoxysmalAutonomicInstabilitywithDystonia(PAID)

non-specificterm“Dysautonomia”diagnosisofPAID

requiresatleastone(otherwiseundefined)daily

paroxysmoccurringforatleast3daystofulfil

criteria第13页，课件共25页，创作于2023年2月目前较为接受的名称Paroxysmalsympathetichyperactivityaftertraumaticbraininjury

PSHFernandez-OrtegaJF,Prieto-PalominoMA,Garcia-CaballeroM,Galeas-LopezJL,Quesada-GarciaG,BaguleyIJ.Paroxysmalsympathetichyperactivityaftertraumaticbraininjury:clinicalandprognosticimplications.JNeurotrauma.2012;29(7):1364-70.第14页，课件共25页，创作于2023年2月

诊断标准—争议Baguley等以具有上述7项中的5项作为诊断依据。Blackman等拟定了更为严格的诊断标准,要求有严重脑损伤(RanchoLosAmigos量表认知功能≤Ⅳ)、体温>38.5&、脉搏>130次/min、呼吸>20次/min、躁动、多汗、肌张力障碍,上述症状每天最少发作1次、持续最少3d,并排除其他疾病。Rabinstein认为该标准过于严格,漏诊的患者会因得不到相应处理而对预后不利。第15页，课件共25页，创作于2023年2月鉴别诊断需要与感染(尤其是颅内感染)、间脑癫痫、颅内压升高(减压窗膨出、脑脊液压力升高)、抗精神病药物引起的恶性综合征(使用多巴胺受体阻滞剂或激动剂)、抗抑郁药引起的5-羟色胺综合征、脊髓损伤(T6~8以上)后自主神经反射异常(尤其合并脑外伤时)、脑外伤后精神障碍、恶性高热、麻醉药物戒断、药物撤离综合征(如巴氯芬的减量过快或突然撤药)等鉴别。而当与上述疾病交织存在时诊断更加复杂,但上述疾病应首先给予排除以免延误病情处理。第16页，课件共25页，创作于2023年2月BaguleyIJ,

HeriseanuRE,

CameronID,

NottMT,

Slewa-YounanS.ACriticalReviewofthePathophysiologyofDysautonomiaFollowingTraumaticBrainInjury.NeurocritCare.

2008;8(2):293-300.

下丘脑自主神经功能损伤或与皮质、皮质下、脑干

神经核团联系中断;交感、副交感平衡失调;

DisconnectiontheoriessuggestthatDysautonomiafollowsthereleaseofoneormoreexcitatorycentresfromhighercentrecontrol脑干和间脑在失去皮质、皮质下结构控制后的释放现象disconnectiontheory,theExcitatory:InhibitoryRatio(EIR)Model,suggeststhecausativebrainstem/diencephaliccentresareinhibitoryinnature,withdamagereleasingexcitatoryspinalcordprocesses.可能的机制第17页，课件共25页，创作于2023年2月AnatomicalmechanismanatomicalandphysiologicalevidencesuggeststhatDysautonomicparoxysmsaremoreconsistentlyassociatedwithmesencephalic

ratherthandiencephaliclesionsparoxysmalepisodescanbetriggeredbyenvironmentaleventsandminimisedbyvariousbutpredictableneurotransmittereffects.第18页，课件共25页，创作于2023年2月excitatory:inhibitoryratio(EIR))

SEI,spinalexcitatory:inhibitorycentre;BEI,

brainstemexcitatory:inhibitorycentre;MC,motorcentres;

+/,excitatory/inhibitorypathways.第19页，课件共25页，创作于2023年2月NeurotransmitterEffectsOpiateanddopaminergicpathways：

Morphinesettledbothhyperdynamiccardiacfunctionandposturing；bromocriptinedecreasedtemperatureandsweatingclonidinecontrolledbloodpressurebutdidnotobviouslyaffecteitherthenumberofDysautonomicepisodesorthesubject’stemperaturepropanololdecreasescirculatingcatecholamines,andreducesbothcardiacworkandcatabolicdriveGABAßagonistbaclofen；ITBactsoninhibitoryinterneuronsinthespinalcord,gabapentin

(GABAɑ2δ)appearedtoreducethenumberandseverityofparoxysmsandallowedanoverallreductioninothermedications,includingITB,withoutarecurrenceofsymptoms第20页，课件共25页，创作于2023年2月典型病例病例简介：男，27岁，外伤致左额硬膜下血肿清除术后16天，睁眼昏迷(VS)，GCS4分。

PSH表现：呼吸↑心率↑大汗↑体温40肌紧张血压↑

1次/4~6h。