Diencephalic Seizures Research Articles

Understanding paroxysmal sympathetic hyperactivity after traumatic brain injury.

Background:Paroxysmal sympathetic hyperactivity (PSH) is a condition occurring in a small percentage of patients with severe traumatic brain injury (TBI). It is characterized by a constellation of symptoms associated with excessive adrenergic output, including tachycardia, hypertension, tachypnea, and diaphoresis. Diagnosis is one of exclusion and, therefore, is often delayed. Treatment is aimed at minimizing triggers and pharmacologic management of symptoms.Methods:A literature review using medline and cinahl was conducted to identify articles related to PSH. Search terms included paroxysmal sympathetic hyperactivity, autonomic storming, diencephalic seizures, and sympathetic storming. Reference lists of pertinent articles were also reviewed and these additional papers were included.Results:The literature indicates that the understanding of PSH following TBI is in its infancy. The majority of information is based on small case series. The review revealed treatments that may be useful in treating PSH.Conclusions:Nurses play a critical role in the identification of at-risk patients, symptom complexes, and in the education of family. Early detection and treatment is likely to decrease overall morbidity and facilitate recovery. Further research is needed to establish screening tools and treatment algorithms for PSH.

Paroxysmal Sympathetic Hyperactivity After Traumatic Brain Injury

A 35-year-old male was the unrestrained driver in a rollover motor vehicle accident from which he was ejected. He was initially comatose, with anisocoria and bilaterally unreactive pupils, absent oculocephalic, corneal, cough and gag reflexes, and no motor response to painful stimulus, but initiating respirations on his own (GCS 3T, FOUR score E0 M0 B0 R1 [1]). Shortly after admission, he developed extensor posturing, elevating his exam to GCS 4T, FOUR score E0 M1 B0 R1. However, his exam did not improve further. Head CT demonstrated small petechial hemorrhages at the gray/white junction, corpus callosum, basal ganglia, and in the interpeduncular cistern, consistent with diffuse axonal injury (Fig. 1). An intracranial pressure monitor was placed, and intracranial pressures were wellcontrolled over the next several days without requiring any interventions. Three days after the accident, the patient developed intermittent episodes of tachycardia with tachypnea, hypertension, fever, profuse sweating, and brisk extensor posturing, consistent with paroxysmal sympathetic hyperactivity [2, 3] (Video in Supplementary material). Paroxysmal sympathetic hyperactivity (PSH) can occur following traumatic brain injury with axonal shear injury, due to disinhibition of subcortical sympathoexcitatory structures [3]. This may have an early and late onset, and is most frequently seen in younger patients. The classic features of these episodes include at least four of the following: profuse sweating, tachycardia, hypertension, tachypnea, fever and extensor posturing, and occur transiently without any other cause [4]. PSH has been previously called diencephalic seizures, but EEGs in these patients have always been normal. The typical clinical features were present in our patient, and were never associated with twitches or decrease in responsiveness that may indicate seizures. PSH typically responds most effectively to a combination of opiate agonist and nonselective beta blockade [4, 5]. Bromocriptine and clonidine may also be used, but with less consistent results [4, 5], and gabapentin is gaining more widespread use for long term effectiveness. In our patient, the episodes were initially treated with beta blockade with propranolol, but did not respond. A combination of clonidine and morphine given during acute episodes was most effective in halting them. Gabapentin was started two days later for longer-term control. However, his neurologic exam failed to improve, care was withdrawn at the strong request of the family and he expired soon after extubation. Paroxysmal sympathetic hyperactivity is a common occurrence in catastrophic neurologic injuries leading to persistent vegetative state. These manifestations are often mistaken for rigors or convulsions and are commonly inadequately treated. Electronic supplementary material The online version of this article (doi:10.1007/s12028-010-9381-y) contains supplementary material, which is available to authorized users.

Endoscopic diagnosis and treatment of infants with posthemorrhagic hydrocephalus

Objective To study the application of flexible endoscope for diagnosis and treatment of infants with posthemorrhagic hydrocephalus. Method 28 cases of infants with posthemorrhagic hydrocephalus were diagnosed and treated with flexible neuron-endoscope in our hospital, from April 2006 to October 2008. Intraventricular haemorrhage in 25, subarachnoid hemorrhage in 2 and infratentorial subdural hematoma in 1. Ventricle irrigation was performed with flexible neuro-endoscope in all patients except 1 hematoma cavity irrigation in the case of infratentorial subdural hematoma. Followed third ventriculostomy in 18 ,simultaneous choroid plexus cauterization in 7 ,lamina terminals fenestration in 4 and the multi septum fenestration in the ventricles in 1. Endoscopic opening of the foramen of magendie with transaqueductal approach in 3. Endoscopic aqueductoplasty in 6. Results Among 28 cases of infants with posthemorrhagic hydrocephalus, only 17 diagnoses occupied 60. 7% (17/28) were defined preoperatively by neural images and the other 11 were diagnosed by overall exploration to the ventricular system under flexible endoscope. Postoperative diencephalic seizures occurred in 6, obstruction in basal cistern was defined by second ETV in 2 patients on 80 days and 7 months after operation respectively. Good results showed in the follow up of 2 to 35 months(median 13.5 months) with no complications such as intraventricular infection or subdural effusion. Conclusions Overall exploration to the ventricular system under flexible endoscope is reliable for diagnosis of posthemorrhagic hydrocephalus. Ventricle irrigation to evacuate the blood blot as far as possible is benefit to decrease the opportunity of obstruction of the stoma or shunt catheter. Second ETV is worth to advocate to identify the cause of unsatisfactory operative results. Key words: Cerebral hemorrhage; Hydrocephalus; Infants; Flexible neuroendoscope

Arc de cercle and dysautonomia from anoxic injury

Autonomic dysregulation and catatonic posturing are well described following acute cerebral injury. Others have referred to this as diencephalic seizures, sympathetic storms, midbrain dysregulatory syndrome, and, most recently, paroxysmal autonomic instability with dystonia. Some of these syndromes can evolve into malignant catatonia requiring electroconvulsive therapy. Here we report a case of hanging associated anoxic brain injury resulting in severe dysautonomia and an extreme opisthotonus (arc de cercle).

Does higher cardiovascular response to ECT predict early antidepressant effect?

Background: Effects of diencephalic seizure generalization during ECT, e.g., cardiovascular response, may be relevant in indexing its therapeutic potency. A trend for greater rate pressure product (RPP=heart rate×systolic blood pressure) response to modified ECT in responders than in nonresponders is reported. Atropine used in modified ECT is known to increase RPP. This study examined if cardiovascular response during ECT with or without atropine predicts antidepressant effect. Methods: Twenty nine consenting, major depressive disorder patients received ECTs. Atropine premedication was randomly withheld in the second or third ECT session. RPP was recorded during ECT. Severity of depression was measured at twice weekly intervals. Results: Fifteen patients remitted at the end of 2 weeks. These early remitters had significantly higher poststimulus RPP than the rest in the ECT session without atropine but not so in the session with atropine. Cumulative poststimulus RPP predicted the early antidepressant response. Corresponding motor or EEG seizure durations were not associated with antidepressant effect. Limitations: Most patients continued to receive antidepressants. ECT stimulus laterality was not controlled. The study focussed on only short term antidepressant effects. Conclusions: RPP response to ECT recorded under no-atropine condition may reflect its physiological effects relevant to therapeusis and may have the potential to index seizure adequacy.

Acute hypothalamic instability in traumatic brain injury: A case report

Thorley RR, Wertsch JJ, Klingbeil GE. Acute hypothalamic instability in traumatic brain injury: a case report. Arch Phys Med Rehabil 2001;82:246-9. Acute hypothalamic instability occurs in patients with traumatic brain injury (TBI). It usually occurs in the form of autonomic dysfunction syndrome (also known as diencephalic seizures or paroxysmal sympathetic storms); however, there are other causes of acute hypothalamic instability of which the clinician must be aware. Neuroleptic malignant syndrome, malignant hyperthermia, autonomic dysfunction syndrome, and lethal catatonia are all syndromes that clinically present as signs and symptoms of acute hypothalamic instability. Because of the lethal potential of these syndromes, clinicians who care for patients with TBI must be aware of the various syndromes, their clinical presentation, and their treatment. We present a case of life-threatening acute hypothalamic instability in a patient with TBI.

Sympathetic storms in a child with a midbrain glioma: a variant of diencephalic seizures

The authors report the unusual case of a 7-year-old child, one of the youngest reported to date, who developed repeated episodes of sympathetic hyperactivity after surgical resection of a midbrain glioma. These paroxysmal events were similar to previously described diencephalic seizures. However, there was no evidence of epileptogenic activity on electroencephalography, and radiologic imaging did not reveal hydrocephalus or intraparenchymal hemorrhage. In this report, clinical features are described of this patient, along with the novel use of clonidine—a sympathetic blocking agent—in his treatment, published reports are reviewed on diencephalic seizures, and steps are recommended in the treatment of a patient who presents in this manner. The authors believe that diencephalic seizures can present with a spectrum of autonomic features, and treatment should be tailored with the appropriate pharmacologic blockade.

Effects of electroconvulsive therapy on plasma vasopressin and oxytocin

Background: Animal studies suggest that vasopressin has cognitive-enhancing properties and oxytocin may have amnestic effects. A clinical report suggests that the acute increase in oxytocin-associated neurophysin predicts clinical response to electroconvulsive therapy (ECT) in depressed patients. Methods: Medication-free patients with major depression were randomized to receive right unilateral or bilateral ECT administered with electrical stimulus intensity at either just above seizure threshold or at 150% above seizure threshold. The associations between plasma vasopressin, oxytocin, ECT treatment parameters, clinical outcome, and cognitive effects were assessed. Results: The sample comprised 55 patients. At the second ECT, patients receiving ECT at 150% above initial seizure threshold had significantly greater increases in plasma vasopressin than patients receiving low-dose ECT ( ps < .01–.04), with no effects of electrode placement. At the second and ninth ECT treatments, the vasopressin or oxytocin surges were not associated with clinical improvement, seizure duration, time to orientation, or memory test performance. There were inverse trend-level associations between the acute surge in oxytocin levels at the ninth ECT and clinical response, contradicting a report in the literature. Conclusions: Overall, these findings do not support the hypothesis that diencephalic seizure propagation is central to the mechanism of action of ECT.

Paroxysmal sympathetic storms ("diencephalic seizures") after severe diffuse axonal head injury.

Paroxysmal sympathetic storms ("diencephalic seizures") after severe diffuse axonal head injury.

Paroxysmal Sympathetic Storms (“Diencephalic Seizures”) After Severe Diffuse Axonal Head Injury

We describe a patient with a severe traumatic head injury who exhibited paroxysmal sympathetic storms, similar to those described in "diencephalic seizures." No epileptiform activity was evident on electroencephalography, and therapeutic levels of anticonvulsants failed to alter the spells; however, use of morphine sulfate abolished them. The features of this and several previously reported cases refute the primary roles of the diencephalon and seizures in this syndrome. Rather, in the setting of already compromised autonomic neuronal integrity, subtle fluctuations in intraventricular pressure or activation of reflexes triggered from muscle mechanoreceptors or chemoreceptors during episodes of hypertonia are more likely. "Paroxysmal sympathetic storms," a more appropriate descriptive term for these phenomena, should be recognized; thus, unnecessary diagnostic evaluations can be minimized, and appropriate therapy can be initiated.

Prolactin response to electroconvulsive therapy: Effects of electrode placement and stimulus dosage

It is unclear whether the serum prolactin (PRL) surge following electroconvulsive therapy (ECT) is a marker of optimal ECT administration. We investigated the relations among PRL surge, stimulus parameters, and outcome in major depressive disorder (MDD). Seventy-nine patients with MDD were randomized in a double-blind trial to right unilateral (RUL) or bilateral (BL), and to low-dose (just above seizure threshold) or high-dose (2.5 x threshold) ECT. Change in PRL (delta PRL) varied among treatment groups, with significant effects of electrode placement (BL > RUL, p < .006), electrical dosage (high > low, p < .04), and gender (female > male, p < .005). There was no evidence that clinical improvement was associated with greater PRL surge. Although delta PRL varied with parameters impacting on response rates, these data indicate the PRL surge cannot serve as a useful index of clinically effective treatment. This finding does not support the view that diencephalic seizure propagation is necessary for ECT to exert therapeutic effects.

Diencephalic Seizures

Intractable complex partial and diencephalic seizures in 1 patient are being treated effectively by intermittent daily electrical stimulation in the right thalamus in conjunction with phenytoin, 200 mg/day, Electrical stimulation in the right thalamus was found to suppress spike and sharp wave discharge activity temporarily in the right thalamus and in the left parietal and right scalp leads. It was postulated that beneficial effects from electrical stimulation were due to electrically ‘jamming a low-threshold discharge system’.