Dysautonomia after pediatric brain injury

Abstract

AIM Dysautonomia after brain injury is a diagnosis based on fever, tachypnea, hypertension, tachycardia, diaphoresis, and/or dystonia. It occurs in 8 to 33% of brain-injured adults and is associated with poor outcome. We hypothesized that brain-injured children with dysautonomia have worse outcomes and prolonged rehabilitation, and sought to determine the prevalence of dysautonomia in children and to characterize its clinical features. METHOD We developed a database of children (n=249, 154 males, 95 females; mean (SD) age 11y 10mo [5y 7mo]) with traumatic brain injury, cardiac arrest, stroke, infection of the central nervous system, or brain neoplasm admitted to The Children’s Institute of Pittsburgh for rehabilitation between 2002 and 2009. Dysautonomia diagnosis, injury type, clinical signs, length of stay, and Functional Independence Measure for Children (WeeFIM) testing were extracted from medical records, and analysed for differences between groups with and without dysautonomia. RESULTS Dysautonomia occurred in 13% of children with brain injury (95% confidence interval 9.3–18.0%), occurring in 10% after traumatic brain injury and 31% after cardiac arrest. The combination of hypertension, diaphoresis, and dystonia best predicted a diagnosis of dysautonomia (area under the curve=0.92). Children with dysautonomia had longer stays, worse WeeFIM scores, and improved less on the score’s motor component (all p≤0.001). INTERPRETATION Dysautonomia is common in children with brain injury and is associated with prolonged rehabilitation. Prospective study and standardized diagnostic approaches are needed to maximize outcomes.

Unresponsive hypertension in a child with meningoencephalitis due to paroxysmal sympathetic hyperactivity

“…The prevalence in children ranges from 6.4% to 13% following brain injury 6'7 . In one study, the underlying causes for PSH were traumatic brain injury (58%), post cardiac arrest anoxic brain injury (24%), infections (9%) and brain neoplasms (6%) 6 . PSH was three times more common following cardiac arrest than traumatic brain injury in children 6 .…”

“…Although long term sequelae of PSH are not well established in adults, one study in children showed that it is associated with longer rehabilitation and worse functional outcome 6 . There is no consensus on the optimum management strategy of this potentially life threatening condition 6 , most evidence being limited to isolated case reports and small case series 2 . Most management protocols are directed towards amelioration of the overactive sympathetic autonomic system and reduction of the motor hyperactivity 2,6 .…”

“…There is no consensus on the optimum management strategy of this potentially life threatening condition 6 , most evidence being limited to isolated case reports and small case series 2 . Most management protocols are directed towards amelioration of the overactive sympathetic autonomic system and reduction of the motor hyperactivity 2,6 . General principles of management of PSH include adequate hydration, effective analgesia, avoidance of triggers, providing a low-stimulation environment, treating hyperthermia and pharmacological agents 6,11 .…”

“…Most management protocols are directed towards amelioration of the overactive sympathetic autonomic system and reduction of the motor hyperactivity 2,6 . General principles of management of PSH include adequate hydration, effective analgesia, avoidance of triggers, providing a low-stimulation environment, treating hyperthermia and pharmacological agents 6,11 . Pharmacological therapy for PSH involves 3 strategies 4,11 .…”

“…Main clinical manifestations of PSH are episodes of fever, tachypnoea, tachycardia, hypertension, diaphoresis and dystonia 6 . Some may have pupillary dilatation and intense flushing 11 .…”