重视脑损伤后发作性交感过度兴奋课件

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,重视脑损伤后发作性交感过度兴奋,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。,Perkes,I,Baguley IJ,Nott MT,Menon DK.A review 1.of paroxysmalsympathetic hyperactivity after acquired brain injury.Ann Neurol2010;68:126135.,tachycardia(120beats/min),tachypnea(30/min),systolic hypertension(160mmHg),hyper/hypothermia,excessive sweating,decerebration/decortication,increased muscle tone,horripilation,鸡皮疙瘩,and/or,flushing,皮肤发红,is collectively referred to as“dysautonomia”or“paroxysmal sympathetic hyperactivity”syndrome,典型的体温血压图,过山车,发病率高低不一,9.333%.,Kishner S,Augustin J,Strum S.Post head injury autonomic,complications.Last updated 4 October 2006 October 4.,Accessed 18 June 2007.,Fearnside MR,Cook RJ,McDougall P,McNeil RJ.The,westmead head injury project outcome in severe head injury.,A comparative analysis of pre-hospital,clinical and CT,variables.British Journal of Neurosurgery 1993;7:267279.,In the,first post-injury week in ICU,.,Of the whole sample,33%developed heart rates 120/min and respiratory rates 30/min and 25%had blood pressure 160mmHg and temperature 39C at some time in the first week.,Lemke DM.Sympathetic storming after severe traumatic braininjury.Crit Care Nurse 2007;27(1):307.,onset,of dysautonomic paroxysms and various afferent stimuli,both,noxious and non-noxious,.,Such stimuli have included pain,endotracheal suctioning,passive movements such as turning,bathing and muscle,stretching,constipation,便秘,or a kinked catheter,导尿,emotional stimuli,as well as environmental stimuli such as loud,noises,Laxe S,Terr R,Len D,Bernabeu M.How does dysautonomia influence the outcome of traumatic brain injured patientsadmitted in a neurorehabilitation unit?Brain Inj.2013;27(12):1383-7.,All patients had been referred to the S.Anna Institute RAN,in the years 19982005 for being in a,VS/UWS,condition.,PSH occurred in,26.1%,of them,with greater incidence after,traumatic than,non-traumatic brain injury(31.9%vs 15.8%).,Outcome was,worse,following,non-traumatic,brain damage,irrespective of PSH and,worst,among non-traumatic subjects,with PSH.,untreated Dysautonomia increases,mortality,through prolonged hyperthermia,excessive catabolism,分解代谢,high catecholamine,儿茶酚胺,levels and spasticity/dystonia,临床值得关注和重视！,Baguley IJ,Heriseanu RE,Gurka JA,Nordenbo A,Cameron ID.Gabapentin in the management of Dysautonomia followingsevere traumatic brain injury:a case series.J Neurol NeurosurgPsychiatr 2007;78(5):53941,it is not possible to completely exclude an,epileptogenic,aetiology for all cases of Dysautonomia,multiple attempts to either identify or treat epilepsy in Dysautonomic patients have produced,negative,results,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,Dysautonomia,临床涵盖多个综合征,These syndromes include NMS,SS,Parkinsonian-Hyperpyrexia Syndrome(PHS),intrathecal baclofen withdrawal,Autonomic Dysreflexia,Malignant Catatonia,紧张症,Malignant Hyperthermia,Stiff Man Syndrome and Irukandji Syndrome.,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,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,Blackman,JA,Patrick PD,Buck ML,Rust Jr.RS.Paroxysmal autonomic instability with dystonia after brain injury.Archives of Neurology 2004;61:321328.,Paroxysmal Autonomic Instability with Dystonia(PAID),non-specific term“Dysautonomia”,diagnosis of PAID,requires at least,one,(otherwise undefined)daily,paroxysm occurring for at least,3,days to fulfil,criteria,目前较为接受的名称,Paroxysmal sympathetic hyperactivity,after traumatic brain injury,PSH,Fernandez-Ortega JF,Prieto-Palomino MA,Garcia-Caballero M,Galeas-Lopez JL,Quesada-Garcia G,Baguley IJ.,Paroxysmal sympathetic hyperactivity after traumatic brain injury:clinical and prognostic implications.J Neurotrauma.2012;29(7):1364-70.,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,(Rancho Los Amigos,量表认知功能,),、体温,38.5&,、脉搏,130,次,/m in,、呼吸,20,次,/m in,、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,3 d,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,。,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。,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.,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;,Disconnection theories suggest that Dysautonomia follows the release of one or more excitatory centres from higher centre control,脑干和间脑在失去皮质、皮质下结构控制后的释放现象,disconnection theory,the Excitatory:Inhibitory Ratio(EIR)Model,suggests the causative brainstem/diencephalic centres are inhibitory in nature,with damage releasing excitatory spinal cord processes.,可能的机制,Ana