Intrathecal baclofen in paroxysmal sympathetic hyperactivity: Impact on oral treatment

Abstract

IntroductionIntrathecal baclofen (ITB) is a commonly used treatment in severe spasticity. The main objective of this study was to assess the impact of ITB on reduction or withdrawal of oral drugs in patients with paroxysmal sympathetic hyperactivity (PSH) after severe traumatic brain injury.MethodsWe retrospectively evaluated 20 patients with PSH due to severe traumatic brain injury who were treated with ITB in a primary care and referral center of neurology. Rates of and time until complete withdrawal or possible reduction in oral baclofen and oral propranolol after ITB treatment were calculated. Moreover, vegetative parameters (heart rate and blood pressure) as well as hypertonic attacks were assessed.ResultsThe median time of complete oral baclofen disposal was 5 ± 3.7 (CI 95% [2.9–7.1], range 0–14) days after ITB pump implantation in 20 of 20 patients, and the median time of complete oral propranolol disposal was 24 ± 62.97 (CI 95% [−7.87–55.87], range 5–191) in 15 of 20 patients. With ITB treatment, PSH improved promptly in all patients with alleviation of heart rate and blood pressure as well as reduction in attacks with motor phenomena. ITB treatment was safe and without complications.ConclusionsITB might facilitate cutting back or dispensing with other conventional oral drugs, such as oral baclofen and oral propranolol. Our study provides further evidence that ITB treatment should be considered in patients with otherwise medically refractory PSH in severe traumatic brain injury. Further prospective multicenter studies are needed to confirm the findings of this study.

European expert consensus on improving patient selection for the management of disabling spasticity with intrathecal baclofen and/or botulinum toxin type A

“…The same question for ITB revealed that ITB is proposed later than BoNT in clinical practice, with the respondents recommending waiting at least 4–6 months (22/77; 28.6%) or more than 6 months (20/77; 26.0%), depending on the cause of spasticity, before treating patients with ITB. This is clearly inappropriate if patients are losing range, particularly in the context of dysautonomia following brain injury, where ITB has been shown to be beneficial ( 42 ).…”

Paroxysmal sympathetic hyperactivity during neurorehabilitation for severe acquired brain injury: current Scandinavian practice and Delphi consensus recommendations

“…For example, although consensus was reached that an intrathecal baclofen pump should be considered for the most severe, refractory cases, this may be unavailable in some centres. While intrathecal baclofen is well established for the treatment of severe spasticity without PSH, and case reports and series exist dating back 20 years (see reference 18 for summary), the quality of evidence remains poor for this potentially effective but invasive intervention.…”

Paroxysmal Sympathetic Hyperactivity After Acquired Brain Injury: An Integrative Review of Diagnostic and Management Challenges

“…Commonly used symptomatic medications include opioids, nonselective β-blockers, α2 agonists, bromocriptine, baclofen, gabapentin, and long-acting benzodiazepines, which are primarily used to lower body temperature, control heart rate, maintain blood pressure, sedate, and relieve spasticity or decrease muscle tone. There have also been case reports on the effectiveness of intrathecal baclofen [ 29 ] and intrarectal administration [ 30 ]. A previous study also found that trazodone was effective in reducing PSH symptoms following a left temporal lobe subcortical hemorrhage in a 49-year-old woman [ 31 ].…”