1/9. Intrathecal baclofen alleviates autonomic dysfunction in severe brain injury.Sympathetic storm phenomena are well known therapeutic problems in patients with severe brain injury. We have treated four patients with intrathecal baclofen (ITB) who suffered from severe hypertension, tachycardia and other sympathetic storm phenomena after different primary events. In all patients conventional therapy with sedatives and antiadrenergic medication had been taken to the upper limits before initiating ITB. Autonomic dysfunction immediately improved in three of four patients. In all patients ITB, via lumbar or ventricular route, proved safe and without complications. The anatomical and pharmacological basis of the GABA-B agonist action on such sympathetic storm phenomena are not yet fully understood. However, the positive results observed in three out of four patients are promising and require further investigation. ITB is a new therapeutic approach to control otherwise unresponsive sympathetic storm phenomena in severe brain injury.- - - - - - - - - - ranking = 1keywords = upper (Clic here for more details about this article) |
2/9. Management of life-threatening autonomic hyper-reflexia using magnesium sulphate in a patient with a high spinal cord injury in the intensive care unit.We report the successful use of i.v. magnesium sulphate to control life-threatening autonomic hyper-reflexia associated with chronic spinal cord injury in the intensive care environment. A 37-yr-old, male was admitted to the intensive care unit with a diagnosis of septic shock and acute renal failure secondary to pyelonephritis. He had been found unresponsive at home following a 2-day history of pyrexia and purulent discharge from his suprapubic catheter. He had sustained a T5 spinal cord transection 20 yr previously. Initial management included assisted ventilation, fluid resuscitation, vasopressor support, and continuous veno-venous haemofiltration. The sepsis was treated with antibiotic therapy and percutaneous nephrostomy drainage of the pyonephrosis. On the fifth day, the patient developed profuse diarrhoea. This was associated with paroxysms of systemic hypertension and diaphoresis, his arterial pressure rising on occasion to 240/140 mm Hg. A diagnosis of autonomic hyper-reflexia was made and a bolus dose of magnesium sulphate 5 g was administered over 15 min followed by an infusion of 1-2 g h(-1). There was an almost immediate decrease in the severity and frequency of the hypertensive episodes. There were no adverse cardiac effects associated with the administration of magnesium, only a slight decrease in minute ventilation as the plasma level approached the upper end of the therapeutic range (2-4 mmol litre(-1)). In view of the beneficial effects observed in this case we advocate further research into the use of magnesium sulphate in the treatment or prevention of autonomic hyper-reflexia secondary to chronic spinal cord injury in the intensive care unit.- - - - - - - - - - ranking = 1keywords = upper (Clic here for more details about this article) |
3/9. hypothermia associated with autonomic dysreflexia after traumatic spinal cord injury.Individuals with traumatic upper thoracic and cervical spinal cord injuries are at increased risk for the development of both thermoregulatory dysfunction and autonomic dysreflexia. It is unclear, however, what effect reflex autonomic sympathetic outflow has on thermoregulatory dysfunction during episodes of autonomic dysreflexia. The following case of an individual with C5 tetraplegia and both thermoregulatory dysfunction and autonomic dysreflexia illustrates the profound effects that the autonomic nervous system may have on body temperature in individuals at risk for this complication.- - - - - - - - - - ranking = 1keywords = upper (Clic here for more details about this article) |
4/9. Charcot joint of the spine, a cause of autonomic dysreflexia in spinal cord injured patients.STUDY DESIGN: Case report of two subjects. OBJECTIVE: Charcot joints of the spine as a cause of autonomic dysreflexia in spinal cord lesions. SETTING: Stoke Mandeville Hospital, UK. METHOD: Two patients with long standing spinal cord lesions developed symptoms of headaches and sweating associated with sitting up and transfers. In both cases no other cause was found to account for autonomic dysreflexia. RESULT: Charcot joints of the spine below the level of injury were demonstrated in both cases and symptoms resolved with prolonged bed rest. CONCLUSION: As care of spinally injured patients continues to improve, they live longer and lead a more active lifestyle, it is expected that the incidence and prevalence of Charcot's joints will increase. Therefore the knowledge and heightened awareness of this entity, early diagnosis and detection with plain x-rays for urinary surveillance, may reduce the morbidity in spinal cord injured patients.- - - - - - - - - - ranking = 111.43048871806keywords = headache (Clic here for more details about this article) |
5/9. An unusual cause of autonomic dysreflexia: pheochromocytoma in an individual with tetraplegia.BACKGROUND: autonomic dysreflexia (AD) is a frequent, serious acute syndrome that occurs in patients with spinal cord lesions at level T6 and above. The syndrome is caused by massive sympathetic discharge that is triggered by a noxious stimulus below the level of the spinal cord lesion. Pheochromocytomas are rare tumors that present with symptoms similar to AD. methods: Case Report. FINDINGS: A 50-year-old man with C7 American Spinal Injury association scale A tetraplegia presented with episodes of severe headaches and paroxysmal hypertension. He was diagnosed with AD. Despite resolving bladder and bowel problems, he continued to have hypertensive episodes. A CT scan of the abdomen revealed a heterogeneous left adrenal mass. Further workup revealed significantly elevated serum and 24-hour urinary catecholamines. clonidine failed to fully suppress the markedly elevated concentrations of serum catecholamines. These biochemical findings were consistent with the diagnosis of pheochromocytoma. Prior to surgery, the patient was treated with alpha-receptor blockers and volume expansion with intravenous fluids. A left adrenalectomy was performed. The surgical specimen revealed that the adrenal gland was expanded by a spherical mass. The pathologic report was benign pheochromocytoma of the left adrenal gland. CONCLUSION: Clinical symptoms and hypertensive episodes resolved following adrenalectomy. To our knowledge, this is the first reported case of a pheochromocytoma in an individual with spinal cord injury.- - - - - - - - - - ranking = 111.43048871806keywords = headache (Clic here for more details about this article) |
6/9. autonomic dysreflexia: a plastic surgery primer.Plastic surgeons are integral to the management team for patients with spinal cord injuries, with responsibilities including pressure sore management and upper extremity reconstruction. Injury to the spinal cord profoundly disrupts the body's ability to maintain homeostasis. In particular, the autonomic system can become unregulated, resulting in a massive sympathetic discharge called autonomic dysreflexia. autonomic dysreflexia occurs in the majority of patients with injuries above the sixth thoracic vertebra and causes sudden, severe hypertension. If left untreated, autonomic dysreflexia can result in stroke or death. Because this syndrome causes morbidity and mortality, it is crucial for plastic surgeons to be able to recognize and treat autonomic dysreflexia. This article reviews the etiology, symptoms, and treatment of this syndrome.- - - - - - - - - - ranking = 1keywords = upper (Clic here for more details about this article) |
7/9. Delayed complications of discontinuation of intrathecal baclofen therapy: resurgence of dyssynergic voiding, which triggered off autonomic dysreflexia and hydronephrosis.STUDY DESIGN: Case report. OBJECTIVES: To report insidious development of autonomic dysreflexia and hydronephrosis due to dyssynergic voiding following discontinuation of intrathecal baclofen therapy. SETTING: Regional spinal injuries Centre, Southport, UK. methods: A male patient with paraplegia at T-5 (asia-A) had implantation of Medtronic Synchromed 8615 s programmable pump to control intractable spasms. After 4 years, the baclofen pump needed replacement because of battery exhaustion. At this time, he was taking oxybutynin 2.5 mg twice a day. He wore a penile sheath and performed intermittent catheterisation three times a day. Intravenous urography showed no dilatation of pelvicalyceal systems or ureters. During the course of the next 4 months, the dose of baclofen had to be increased gradually to 820 microg/day in order to control the spasms. Investigations revealed disconnection of the tube from the pump. The patient decided to undergo explantation of the pump and discontinue intrathecal baclofen therapy altogether. Following removal of the pump, he was prescribed baclofen 20 mg four times a day and diazepam 5 mg twice a day. He continued penile sheath drainage with oxybutynin 2.5 mg twice a day. Although spasms were controlled with oral baclofen and diazepam, he started getting transient, mild headache during reflex voiding. After nearly 2 years, he developed unbearable and pounding headache while passing urine. RESULTS: The dose of oxybutynin was increased to modified release formulation, 20 mg, once daily. He was prescribed modified release alfuzosin 10 mg once a day. Indwelling urethral catheter drainage was instituted. Intravenous urography showed dilation of left renal pelvis and calyces, and left ureter. After a fortnight, the dose of modified release oxybutynin was increased further to 25 mg once a day. After a month, he started performing self-catheterisation every 3 h and symptoms of autonomic dysreflexia subsided completely. A follow-up intravenous urography performed 6 months later, showed normal appearances of the left kidney. CONCLUSION: Spinal cord injury patients, in whom intrathecal baclofen therapy is terminated, need close monitoring of their urological status. Medications, which are prescribed for neuropathic bladder, and the method of bladder drainage, may need suitable changes, as discontinuation of intrathecal baclofen therapy can result in reappearance of detrusor-sphincter dyssynergia in previously susceptible patients.- - - - - - - - - - ranking = 222.86097743613keywords = headache (Clic here for more details about this article) |
8/9. Charcot arthropathy in relation to autonomic dysreflexia in spinal cord injury: case report and review of the literature.Charcot spinal arthropathy has been described as a late complication of spinal cord injury. In patients with these injuries in whom the spine below the level of injury is insensate, joint trauma can progress until spinal instability ensues. The authors describe the case of a 50-year-old man with complete C-8 tetraplegia who experienced a 4-month history of episodic severe headaches, profuse sweating over his face and arms, and episodic severe hypertension in addition to a "grinding" sensation in the lower back. Charcot arthropathy at the T11-12 levels with pathological mobility was demonstrated on neuroimaging. Intraoperatively, a complete spinal cord transection was identified. Anterior and posterior thoracolumbar fusion across the mobile segment resulted in complete amelioration of signs and symptoms of autonomic dysreflexia. This entity, a common condition in the setting of spinal cord injury, has many triggers. Definitive treatment is targeted at the removal of the underlying cause. As demonstrated here, Charcot spinal arthropathy can act as a powerful trigger for induction of autonomic dysreflexia. Treatment of the associated spinal instability resulted in eradication of all signs and symptoms of the dysreflexia.- - - - - - - - - - ranking = 111.43048871806keywords = headache (Clic here for more details about this article) |
9/9. autonomic dysreflexia triggered by an unstable lumbar spine in a quadriplegic patient.A 40 year-old man with C5 complete quadriplegia, had L2-L3 pyogenic spondylitis treated with debridement and fusion of the lumbar spine with left iliac bone graft. Three months later he developed symptoms of autonomic dysreflexia, including headache, cold sweating, and hypertension whenever he was in an upright position. These symptoms resolved after lying down. Roentgenograms of the lumbar spine revealed absorption of the bone graft at the L2-L3 level. A spinal stabilization procedure was done after eight weeks of antibiotic therapy under the impression of unstable spine caused by pyogenic spondylitis. Symptoms were relieved immediately following the surgery. This report may be helpful for physicians caring for quadriplegic patients with autonomic dysreflexia induced by an unstable spine.- - - - - - - - - - ranking = 111.43048871806keywords = headache (Clic here for more details about this article) |