重視腦損傷后發(fā)作性交感過興奮百演示

（優(yōu)選）重視腦損傷后發(fā)作性交感過度興奮百度現(xiàn)在是1頁\一共有24頁\編輯于星期二中重度腦損傷患者的臨床表現(xiàn)中,常可見到一組發(fā)作性的高熱、多汗、呼吸急促、心動過速、血壓升高、瞳孔改變、煩躁并全身強(qiáng)直、陣攣等肌張力障礙等癥候群?，F(xiàn)在是2頁\一共有24頁\編輯于星期二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雞皮疙瘩

and/orflushing皮膚發(fā)紅

iscollectivelyreferredtoas“dysautonomia”or“paroxysmalsympathetichyperactivity”syndrome現(xiàn)在是3頁\一共有24頁\編輯于星期二典型的體溫血壓圖過山車現(xiàn)在是4頁\一共有24頁\編輯于星期二發(fā)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.現(xiàn)在是5頁\一共有24頁\編輯于星期二LemkeDM.Sympatheticstormingafterseveretraumaticbrain

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

orakinkedcatheter導(dǎo)尿,emotionalstimuli,aswellasenvironmentalstimulisuchasloudnoises

現(xiàn)在是6頁\一共有24頁\編輯于星期二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分解代謝,

highcatecholamine兒茶酚胺

levelsandspasticity/dystonia臨床值得關(guān)注和重視！現(xiàn)在是7頁\一共有24頁\編輯于星期二BaguleyIJ,HeriseanuRE,GurkaJA,NordenboA,CameronID.

GabapentininthemanagementofDysautonomiafollowing

severetraumaticbraininjury:acaseseries.JNeurolNeurosurg

Psychiatr2007;78(5):539–41itisnotpossibletocompletelyexcludeanepileptogenicaetiologyforallcasesofDysautonomiamultipleattemptstoeitheridentifyortreatepilepsyinDysautonomicpatientshaveproduced

negativeresults現(xiàn)在是8頁\一共有24頁\編輯于星期二

常見原因腦外傷、腫瘤、腦積水、顱內(nèi)出血、

蛛網(wǎng)膜下腔出血、缺氧性腦病,其中腦外傷是最常見的原因也有各種原因?qū)е碌娜毖跣阅X病現(xiàn)在是9頁\一共有24頁\編輯于星期二

Dysautonomia臨床涵蓋多個綜合征ThesesyndromesincludeNMS,SS,Parkinsonian-HyperpyrexiaSyndrome(PHS)intrathecalbaclofenwithdrawalAutonomicDysreflexiaMalignantCatatonia緊張癥MalignantHyperthermiaStiffManSyndromeandIrukandjiSyndrome.現(xiàn)在是10頁\一共有24頁\編輯于星期二

針對腦損傷后的癥候群--命名創(chuàng)傷性腦損傷后自主神經(jīng)功能障礙、自主神經(jīng)功能障礙綜合征、急性下丘腦功能不穩(wěn)、下丘腦中腦功能失調(diào)綜合征、間腦綜合征、間腦發(fā)作、發(fā)作性自主神經(jīng)或交感神經(jīng)爆發(fā)、中樞熱、高熱伴持續(xù)性肌肉收縮現(xiàn)在是11頁\一共有24頁\編輯于星期二

病因區(qū)別腦損傷后發(fā)作性自主神經(jīng)功能障礙家族性遺傳性自主神經(jīng)功能障礙、病毒感染后自主神經(jīng)功能障礙、Guillain-Barre綜合征伴發(fā)的自主神經(jīng)功能障礙、脊髓損傷后的自主神經(jīng)功能障礙現(xiàn)在是12頁\一共有24頁\編輯于星期二BlackmanJA,PatrickPD,BuckML,RustJr.RS.Paroxysmalautonomicinstabilitywithdystoniaafterbraininjury.

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

non-specificterm“Dysautonomia”diagnosisofPAID

requiresatleastone(otherwiseundefined)daily

paroxysmoccurringforatleast3daystofulfil

criteria現(xiàn)在是13頁\一共有24頁\編輯于星期二目前較為接受的名稱Paroxysmalsympathetichyperactivityaftertraumaticbraininjury

PSHFernandez-OrtegaJF,Prieto-PalominoMA,Garcia-CaballeroM,Galeas-LopezJL,Quesada-GarciaG,BaguleyIJ.Paroxysmalsympathetichyperactivityaftertraumaticbraininjury:clinicalandprognosticimplications.JNeurotrauma.2012;29(7):1364-70.現(xiàn)在是14頁\一共有24頁\編輯于星期二

診斷標(biāo)準(zhǔn)—爭議Baguley等以具有上述7項中的5項作為診斷依據(jù)。Blackman等擬定了更為嚴(yán)格的診斷標(biāo)準(zhǔn),要求有嚴(yán)重腦損傷(RanchoLosAmigos量表認(rèn)知功能≤Ⅳ)、體溫>38.5&、脈搏>130次/min、呼吸>20次/min、躁動、多汗、肌張力障礙,上述癥狀每天最少發(fā)作1次、持續(xù)最少3d,并排除其他疾病。Rabinstein認(rèn)為該標(biāo)準(zhǔn)過于嚴(yán)格,漏診的患者會因得不到相應(yīng)處理而對預(yù)后不利。現(xiàn)在是15頁\一共有24頁\編輯于星期二鑒別診斷需要與感染(尤其是顱內(nèi)感染)、間腦癲癇、顱內(nèi)壓升高(減壓窗膨出、腦脊液壓力升高)、抗精神病藥物引起的惡性綜合征(使用多巴胺受體阻滯劑或激動劑)、抗抑郁藥引起的5-羥色胺綜合征、脊髓損傷(T6~8以上)后自主神經(jīng)反射異常(尤其合并腦外傷時)、腦外傷后精神障礙、惡性高熱、麻醉藥物戒斷、藥物撤離綜合征(如巴氯芬的減量過快或突然撤藥)等鑒別。而當(dāng)與上述疾病交織存在時診斷更加復(fù)雜,但上述疾病應(yīng)首先給予排除以免延誤病情處理?，F(xiàn)在是16頁\一共有24頁\編輯于星期二BaguleyIJ,

HeriseanuRE,

CameronID,

NottMT,

Slewa-YounanS.ACriticalReviewofthePathophysiologyofDysautonomiaFollowingTraumaticBrainInjury.NeurocritCare.

2008;8(2):293-300.

下丘腦自主神經(jīng)功能損傷或與皮質(zhì)、皮質(zhì)下、腦干

神經(jīng)核團(tuán)聯(lián)系中斷;交感、副交感平衡失調(diào);

DisconnectiontheoriessuggestthatDysautonomiafollowsthereleaseofoneormoreexcitatorycentresfromhighercentrecontrol腦干和間腦在失去皮質(zhì)、皮質(zhì)下結(jié)構(gòu)控制后的釋放現(xiàn)象disconnectiontheory,theExcitatory:InhibitoryRatio(EIR)Model,suggeststhecausativebrainstem/diencephaliccentresareinhibitoryinnature,withdamagereleasingexcitatoryspinalcordprocesses.可能的機(jī)制現(xiàn)在是17頁\一共有24頁\編輯于星期二AnatomicalmechanismanatomicalandphysiologicalevidencesuggeststhatDysautonomicparoxysmsaremoreconsistentlyassociatedwithmesencephalic

ratherthandiencephaliclesionsparoxysmalepisodescanbetriggeredbyenvironmentaleventsandminimisedbyvariousbutpredictableneurotransmittereffects.現(xiàn)在是18頁\一共有24頁\編輯于星期二excitatory:inhibitoryratio(EIR))

SEI,spinalexcitatory:inhibitorycentre;BEI,

brainstemexcitatory:inhibitorycentre;MC,motorcentres;

+/,excitatory/inhibitorypathways.現(xiàn)在是19頁\一共有24頁\編輯于星期二NeurotransmitterEffectsOpiateanddopaminergicpathways：

Morphinesettledbothhyperdynamiccardiacfunctionandposturing；bromocriptinedecreasedtemperatureandsweatingclonidinecontrolledbloodpressurebutdidnotobviouslyaffecteitherthenumberofDysautonomicepisodesorthesubject’stemperaturepropanololdecreasescirculatingcatecholamines,andreducesbothcardiacworkandcatabolicdriveGABA?agonistbaclofen；ITBactsoninhibitoryinterneuronsinthespinalcord,gabapentin

(GABAɑ2δ)appearedtoreducethenumberandseverityofparoxysmsandallowedanoverallreductioninothermedications,includingITB,withoutarecurrenceofsymptoms現(xiàn)在是20頁\一共有24頁\編輯于星期二典型病例病例簡介：男，27歲，外傷致左額硬膜下血腫清除術(shù)后16天，睜眼昏迷(VS)，GCS4分。

PSH表現(xiàn)：呼吸↑心