818 zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA CLINICAL NOTES zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Fever of Central Origin in Traumatic With Propranolol zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Jay Merlin Meythaler, MD, JD, Alvin Macon Stinson III, MD Brain Injury Controlled ABSTRACT. Meythaler JM, Stinson AM. Fever of central origin in traumatic brain injury controlled with propranolol. Arch Phys Med Rehabil 1994;75:816-8. a Central fevers are known to develop in traumatic brain injury (TBI) and are believed to be caused by injury involving the hypothalamus. Described are three patients admitted with very severe TBI secondary to motor vehicle accidents. Initial Glasgow Coma Score ratings were 3 or 4. Head computed tomography (CT) scans showed intraventricular hemorrhage in two cases and no focal injury or bleeding in the third. All patients had decorticate posturing and symptoms of autonomic dysfunction, manifested by tachycardia and profuse sweating. Each of these patients developed high fevers ranging from 38.9 degrees C to 40.6 degrees C during their hospitaliza- tion course. Centrally mediated fevers were indicated after fever workups failed to show an infectious or inflam- matory source. Propranolol 20 to 30mg every 6 hours reduced the temperatures at least 1.5 degrees C within 48 hours. In each case, when weaning from propranolol was attempted, an increase in temperature to greater than 38.0 degrees C reoccurred within 3 days. Repeat workups for infectious or inflammatory causes of fever were negative. The fevers were reduced after a reinstitution of propranolol. The propranolol was continued until all signs of autonomic dysfunction abated. Central fevers after TBI have been reported to have been treated success- fully with propranolol in two children with decerebrate posturing. Pharmacological, neurophysiological, and anatomic studies provide evidence of a significant central nervous system role in the regulation of blood pressure and temperature. 0 1993 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation There have been numerous studies linking central nervous system (CNS) control to various autonomic functions such as the maintenance of blood pressure and temperature ho- meostasis.‘” Consequently, various autonomic disturbances may be encountered in patients after a CNS insult such as in traumatic brain injury (TBI). Hypertension after TBI may result from increased catecholamine release. increased intra- cranial pressure. or as a consequence of focal lesions to the hypothalamus.‘,3 Hyperthermia is a common finding in the patient with TBI. The most common cause for this fever is infection’.‘; however, fever may also result from deep vein thromboses. fat embolisms, or secondary to certain drug usage.’ On rare occasions, fever is the result of impaired temperature control after injury to the anterior hypothalamus.‘.5.h Various phar- macological approaches have been used to treat these cen- trally mediated fevers. Propranolol is a nonselective beta-blocker that has histori- cally been used to control hypertension, prevent angina pec- toris, and to modify certain cardiac arrhythmias.‘.’ In the TBI patient population. propranolol has also been used to control agitation.” Many of the CNS effects of propranolol are achieved because it is a highly lipophilic compound and From thr Drpartment of Rehnbilutmn Medxine. Univu\lly of Alabamcl at Bir- mmgham, Birmingham. Al.. Submitted for publia[mn December 14. IYY3. Acccptrd in rr\lwd form Februar) 9, 1994. No commercial pan) having a direut tinnncial interrst m the rewlt\ of the rcvxr~h supporting thl\ arti& ha\ or will confer n brnrfit upon the au[hor\ ur upon any r)rpanlxatmn\ with which the author\ are awciated. Reprint rrqur\rs IO Jay M. Meytholer, MD, Depwtment ut Rrhabilitution Medicme. LhGrrGty of Alabama a1 Birmingham. RI4 Spain Rehabilitation Center. LJAB Sta- tion, Bnmingham, AL 35733.7330. ‘Fa I994 bv the Amcr~can Congre\~ 01 R~habilitatiun Medicme and the .Amrr~un Academy ot’.Phykal Mrdicinr and Rrhubihtntiorl 1~003-9993/9~/7507oo2o$3.oo1o thus easily crosses the blood-brain barrier.‘-” Although the effects of beta-blockers on hypertension produced by auto- nomic dysfunction are well known,‘.x the use of propranolol for control of centrally mediated fevers in patients with TBI has been suggested only once.: This article presents three case-control studies describing the effective usage of pro- pranolol to control centrally-mediated with TBI. fevers in patients CASE REPORTS Case 1 Patient is a ?O-year-old woman who suffered a severe TBI after a head-on motor vehicle accident. Her initial Glasgow Coma Score was 3 and the initial head CT scan showed no gross subdural/ epidural hematomas or focal injuries/hemorrhages. Other injuries included multiple facial fractures and an avulsion injury of the right leg. After a I-month acute care hospital course. she was transferred to our rehabilitation unit. On admission. her temperature was 3X.7 degrees C ( 101.7 degrees F 1. Physical examination showed an inability to follow commands. extensive diaphoresis, decorticate posturing. and occasional bilateral spontaneous mov’e- ments of the extremities (right > left). Her cognitive status was at Ranch0 Stage III by the Ranch0 Los Amigos Cognition Scale. Soon after admission, her temperatures increased from 37.7 degrees C (99.X degrees F) to 38.9 degrees C ( 102 degrees F). When the fever work-up failed to show an infectious source. autonomic dysfunction with central fevers was indicated. She wa\ adminis- tered propranolol IOmg every 6 hours on her second hospitalization day. The following day. the propranolol was increased to 70mg every 6 hours. Within 4X hours of starting propranolol; her temper- atures decreased to within 35.1 degrees C (95.3 degrees F) to 37.X degrees C ( 100 degrees Fl. Approximately 2 weeks later. after propranolol therapy was stopped for about I week while she under- went gastrostomy tube placement her temperatures increased to Arch Phys Med Rehabil Vol75, July 1994