Neurological Disorders in the Intensive Care Unit

ABSTRACT

Neurological problems are common among critically ill patients; they often signal that other organs are failing, but are themselves important causes of morbidity and mortality. Cognitive function may suffer as a consequence of septic encephalopathy, the pathophysiology of which is poorly understood; however, the affected patients usually return to their baseline when sepsis resolves. Seizures and cerebrovascular disorders are also common in the intensive care unit. Neuromuscular complications are important causes of failure to wean from mechanical ventilation and lead to substantial long-term morbidity.

KEYWORDS

Acute quadriplegic myopathy - ARDS: acute respiratory distress syndrome - critical illness myopathy - critical illness polyneuropathy - fulminant hepatic failure - seizure - septic encephalopathy

REFERENCES

• 1 Bleck T P. Why isn't this patient awake?.  J Intensive Care Med. 1993;  8 155-156
• 2 Wijdicks E F. Neurologic complications in critically ill patients.  Anesth Analg. 1996;  83 411-419
• 3 Isensee L M, Weiner L J, Hart R G. Neurologic disorders in a medical intensive care unit: a prospective survey.  J Crit Care. 1989;  4 208-210
• 4 Bleck T P, Smith M C, Pierre-Louis S J, Jares J J, Murray J, Hansen C A. Neurologic complications of critical medical illnesses.  Crit Care Med. 1993;  21 98-103
• 5 Komrad M S, Coffey C E, Coffey K S, McKinnis R, Massey E W, Califf R M. Myocardial infarction and stroke.  Neurology. 1984;  34 1403-1409
• 6 Thompson P L, Robinson J S. Stroke after acute myocardial infarction: relation to infarct size.  BMJ. 1978;  2 457-459
• 7 Nathan B R, Bleck T P. Central nervous system complications of critical medical illness. In: Miller DH, Raps EC Critical Care Neurology. Boston; Butterworth-Heineman 1999: 331-340
• 8 Bright R. Reports of Medical Cases Selected with a View of Illustrating the Symptoms and Cure of Diseases, with a Reference to Morbid Anatomy. London; Longman, Rees, Orme, Brown and Green 1827
• 9 Young G B, Bolton C F, Austin T W, Archibald Y M, Gonder J, Wells G A. The encephalopathy associated with septic illness.  Clin Invest Med. 1990;  13 297-304
• 10 Young G B, Bolton C F, Archibald Y M, Austin T W, Wells G A. The electroencephalogram in sepsis-associated encephalopathy.  J Clin Neurophysiol. 1992;  9 145-152
• 11 Zauner C, Gendo A, Kramer L et al.. Impaired subcortical and cortical sensory evoked potential pathways in septic patients.  Crit Care Med. 2002;  30 1136-1139
• 12 Sprung C L, Peduzzi P N, Shatney C H et al.. Impact of encephalopathy on mortality in the sepsis syndrome. The Veterans Administration Systemic Sepsis Cooperative Study Group.  Crit Care Med. 1990;  18 801-806
• 13 Eidelman L A, Putterman D, Putterman C, Sprung C L. The spectrum of septic encephalopathy: definitions, etiologies, and mortalities.  JAMA. 1996;  275 470-473
• 14 Jackson A C, Gilbert J J, Young G B, Bolton C F. The encephalopathy of sepsis.  Can J Neurol Sci. 1985;  12 303-307
• 15 Pendlebury W W, Perl D P, Munoz D G. Multiple microabscesses in the central nervous system: a clinicopathologic study.  J Neuropathol Exp Neurol. 1989;  48 290-300
• 16 Quagliarello V J, Wispelwey B, Long Jr W J, Scheld W M. Recombinant human interleukin-1 induces meningitis and blood-brain barrier injury in the rat: characterization and comparison with tumor necrosis factor.  J Clin Invest. 1991;  87 1360-1366
• 17 du Moulin G C, Paterson D, Hedley-Whyte J, Broitman S A. E. Coli peritonitis and bacteremia cause increased blood-brain barrier permeability.  Brain Res. 1985;  340 261-268
• 18 Dinarello C A, Cannon J G, Wolff S M. New concepts on the pathogenesis of fever.  Rev Infect Dis. 1988;  10 168-189
• 19 De Sarro G B, Masuda Y, Ascioti C, Audino M G, Nistico G. Behavioural and ECoG spectrum changes induced by intracerebral infusion of interferons and interleukin 2 in rats are antagonized by naloxone.  Neuropharmacology. 1990;  29 167-179
• 20 Reyes-Vazquez C, Prieto-Gomez B, Georgiades J A, Dafny N. Alpha and gamma interferons' effects on cortical and hippocampal neurons: microiontophoretic application and single cell recording.  Int J Neurosci. 1984;  25 113-121
• 21 Kadoi Y, Saito S, Kunimoto F, Imai T, Fujita T. Impairment of the brain beta-adrenergic system during experimental endotoxemia.  J Surg Res. 1996;  61 496-502
• 22 Mussack T, Briegel J, Schelling G, Biberthaler P, Jochum M. Effect of stress doses of hydrocortisone on S-100B vs. interleukin-8 and polymorphonuclear elastase levels in human septic shock.  Clin Chem Lab Med. 2005;  43 259-268
• 23 Maekawa T, Fujii Y, Sadamitsu D et al.. Cerebral circulation and metabolism in patients with septic encephalopathy.  Am J Emerg Med. 1991;  9 139-143
• 24 Papadopoulos M C, Davies D C, Moss R F, Tighe D, Bennett E D. Pathophysiology of septic encephalopathy: a review.  Crit Care Med. 2000;  28 3019-3024
• 25 Finelli P F, Uphoff D F. Magnetic resonance imaging abnormalities with septic encephalopathy.  J Neurol Neurosurg Psychiatry. 2004;  75 1189-1191
• 26 Sharshar T, Annane D, de la Grandmaison G L, Brouland J P, Hopkinson N S, Francoise G. The neuropathology of septic shock.  Brain Pathol. 2004;  14 21-33
• 27 Terborg C, Schummer W, Albrecht M, Reinhart K, Weiller C, Rother J. Dysfunction of vasomotor reactivity in severe sepsis and septic shock.  Intensive Care Med. 2001;  27 1231-1234
• 28 Papadopoulos M C, Lamb F J, Moss R F, Davies D C, Tighe D, Bennett E D. Faecal peritonitis causes oedema and neuronal injury in pig cerebral cortex.  Clin Sci (Lond). 1999;  96 461-466
• 29 Ari I, Kafa I M, Kurt M A. Perimicrovascular edema in the frontal cortex in a rat model of intraperitoneal sepsis.  Exp Neurol. 2006;  198 242-249
• 30 Davies D C. Blood-brain barrier breakdown in septic encephalopathy and brain tumours.  J Anat. 2002;  200 639-646
• 31 Semmler A, Okulla T, Sastre M, Dumitrescu-Ozimek L, Heneka M T. Systemic inflammation induces apoptosis with variable vulnerability of different brain regions.  J Chem Neuroanat. 2005;  30 144-157
• 32 Zhan R Z, Fujiwara N, Shimoji K. Regionally different elevation of intracellular free calcium in hippocampus of septic rat brain.  Shock. 1996;  6 293-297
• 33 Weeks S G, Silva C, Auer R N, Doig C J, Gill M J, Power C. Encephalopathy with staphylococcal endocarditis: multiple neuropathological findings.  Can J Neurol Sci. 2001;  28 260-264
• 34 Moller K, Strauss G I, Qvist J et al.. Cerebral blood flow and oxidative metabolism during human endotoxemia.  J Cereb Blood Flow Metab. 2002;  22 1262-1270
• 35 Voigt K, Kontush A, Stuerenburg H J, Muench-Harrach D, Hansen H C, Kunze K. Decreased plasma and cerebrospinal fluid ascorbate levels in patients with septic encephalopathy.  Free Radic Res. 2002;  36 735-739
• 36 Barichello T, Fortunato J J, Vitali A M et al.. Oxidative variables in the rat brain after sepsis induced by cecal ligation and perforation.  Crit Care Med. 2006;  34 886-889
• 37 Esen F, Erdem T, Aktan D et al.. Effect of magnesium sulfate administration on blood-brain barrier in a rat model of intraperitoneal sepsis: a randomized controlled experimental study.  Crit Care. 2005;  9 R18-R23
• 38 Mizock B A, Sabelli H C, Dubin A, Javaid J I, Poulos A, Rackow E C. Septic encephalopathy: evidence for altered phenylalanine metabolism and comparison with hepatic encephalopathy.  Arch Intern Med. 1990;  150 449
• 39 Sprung C L, Cerra F B, Freund H R et al.. Amino acid alterations and encephalopathy in the sepsis syndrome.  Crit Care Med. 1991;  19 753-757
• 40 Basler T, Meier-Hellmann A, Bredle D, Reinhart K. Amino acid imbalance early in septic encephalopathy.  Intensive Care Med. 2002;  28 293-298
• 41 Eggers V, Fugener K, Hein O V et al.. Antibiotic-mediated release of tumour necrosis factor alpha and norharman in patients with hospital-acquired pneumonia and septic encephalopathy.  Intensive Care Med. 2004;  30 1544-1551
• 42 Kunze K. Metabolic encephalopathies.  J Neurol. 2002;  249 1150-1159
• 43 Towne A R, Waterhouse E J, Boggs J G et al.. Prevalence of nonconvulsive status epilepticus in comatose patients.  Neurology. 2000;  54 340-345
• 44 Bleck T P. Sepsis on the brain.  Crit Care Med. 2002;  30 1176-1177
• 45 Nora P M, Bleck T P. Increased intracranial pressure complicating acute hepatic failure.  J Crit Illn. 1989;  4 87-96
• 46 O'Brien C J, Wise R J, O'Grady J G, Williams R. Neurological sequelae in patients recovered from fulminant hepatic failure.  Gut. 1987;  28 93-95
• 47 Norenberg M D, Rao K V, Jayakumar A R. Mechanisms of ammonia-induced astrocyte swelling.  Metab Brain Dis. 2005;  20 303-318
• 48 Bleck T P. Neurologic consequences of fulminant hepatic failure.  Mayo Clin Proc. 1995;  70 195-196
• 49 Canalese J, Gimson A E, Davis C, Mellon P J, Davis M, Williams R. Controlled trial of dexamethasone and mannitol for the cerebral oedema of fulminant hepatic failure.  Gut. 1982;  23 625-629
• 50 Nguyen J H, Yamamoto S, Steers J et al.. Matrix metalloproteinase-9 contributes to brain extravasation and edema in fulminant hepatic failure mice.  J Hepatol. 2005 Nov 7;  , [Epub ahead of print]
• 51 Rama Rao K V, Chen M, Simard J M, Norenberg M D. Suppression of ammonia-induced astrocyte swelling by cyclosporin A.  J Neurosci Res. 2003;  74 891-897
• 52 Ede R J, Gimson A E, Bihari D, Williams R. Controlled hyperventilation in the prevention of cerebral oedema in fulminant hepatic failure.  J Hepatol. 1986;  2 43-51
• 53 Forbes A, Alexander G J, O'Grady J G et al.. Thiopental infusion in the treatment of intracranial hypertension complicating fulminant hepatic failure.  Hepatology. 1989;  10 306-310
• 54 Davenport A, Will E J, Davison A M. Effect of posture on intracranial pressure and cerebral perfusion pressure in patients with fulminant hepatic and renal failure after acetaminophen self-poisoning.  Crit Care Med. 1990;  18 286-289
• 55 Munoz S J, Robinson M, Northrup B et al.. Elevated intracranial pressure and computed tomography of the brain in fulminant hepatocellular failure.  Hepatology. 1991;  13 209-212
• 56 Wijdicks E F, Plevak D J, Rakela J, Wiesner R H. Clinical and radiologic features of cerebral edema in fulminant hepatic failure.  Mayo Clin Proc. 1995;  70 119-124
• 57 Davenport A, Will E J, Losowsky M S. Rebound surges of intracranial pressure as a consequence of forced ultrafiltration used to control intracranial pressure in patients with severe hepatorenal failure.  Am J Kidney Dis. 1989;  14 516-519
• 58 Sen S, Rose C, Ytrebo L M et al.. Effect of albumin dialysis on intracranial pressure increase in pigs with acute liver failure: a randomized study.  Crit Care Med. 2006;  34 158-164
• 59 Keays R, Potter D, O'Grady J, Peachey T, Alexander G, Williams R. Intracranial and cerebral perfusion pressure changes before, during and immediately after orthotopic liver transplantation for fulminant hepatic failure.  Q J Med. 1991;  79 425-433
• 60 Shami V M, Caldwell S H, Hespenheide E E et al.. Recombinant activated factor VII for coagulopathy in fulminant hepatic failure compared with conventional therapy.  Liver Transpl. 2003;  9 138-143
• 61 Jones E A, Basile A S. Does ammonia contribute to increased GABA-ergic neurotransmission in liver failure?.  Metab Brain Dis. 1998;  13 351-360
• 62 Ahboucha S, Butterworth R F. Role of endogenous benzodiazepine ligands and their GABA-A-associated receptors in hepatic encephalopathy.  Metab Brain Dis. 2005;  20 425-437
• 63 Bansky G, Meier P J, Rieder E et al.. Effects of the benzodiazepine receptor antagonist flumazenil in hepatic encephalopathy in humans.  Gastroenterology. 1989;  97 744-750
• 64 Grimm G, Ferenci P, Katzenschlager R et al.. Improvement of hepatic encephalopathy treated with flumazenil.  Lancet. 1988;  2 1392-1394
• 65 Bessman S P, Wang W, Mohan C. Ammonia inhibits insulin stimulation of the Krebs cycle: further insights into the mechanism of hepatic coma.  Neurochem Res. 1991;  16 805-811
• 66 Blom H J, Ferenci P, Grimm G et al.. The role of methanethiol in the pathogenesis of hepatic coma.  Hepatology. 1991;  13 445-454
• 67 Bleck T P. Metabolic encephalopathy. In: Weiner WJ, Shulman LM Emergent and Urgent Neurology. 2nd ed. Philadelphia; Lippincott 1999: 223-253
• 68 Seger D L. Flumazenil-treatment or toxin.  J Toxicol Clin Toxicol. 2004;  42 209-216
• 69 Frucht M M, Bleck T P. Seizures in the intensive care unit patient. In: Delanty M Seizures: Medical Causes and Management. Totowa; Humana Press 2002: 309-318
• 70 Singh B M, Strobos R J. Epilepsia partialis continua associated with nonketotic hyperglycemia: clinical and biochemical profile of 21 patients.  Ann Neurol. 1980;  8 155-160
• 71 Kumar A, Bleck T P. Intravenous midazolam for the treatment of refractory status epilepticus.  Crit Care Med. 1992;  20 483-488
• 72 Prasad A, Worrall B B, Bertram E H, Bleck T P. Propofol and midazolam in the treatment of refractory status epilepticus.  Epilepsia. 2001;  42 380-386
• 73 Rivner M H, Kim S, Greenberg M, Swift T R. Reversible generalized paresis following hypotension: a new neurologic entity.  Neurology. 1983;  33(Suppl 2) 164
• 74 Bolton C F, Brown J D, Sibbald W J. The electrophysiologic investigation of respiratory paralysis in critically ill patients.  Neurology. 1983;  33(Suppl 2) 186
• 75 Roelofs R J, Cerra F, Bielka N, Rosenberg L, Delaney J. Prolonged respiratory insufficiency due to acute motor neuropathy: a new syndrome?.  Neurology. 1983;  33(Suppl 2) 240
• 76 Bolton C F, Gilbert J J, Hahn A F, Sibbald W J. Polyneuropathy in critically ill patients.  J Neurol Neurosurg Psychiatry. 1984;  47 1223-1231
• 77 Bolton C F, Laverty D A, Brown J D, Witt N J, Hahn A F, Sibbald W J. Critically ill polyneuropathy: electrophysiologic studies and differentiation from the Guillain-Barré syndrome.  J Neurol Neurosurg Psychiatry. 1986;  49 563-573
• 78 Zochodne D W, Bolton C F, Wells G A et al.. Critical illness polyneuropathy: a complication of sepsis and multiple organ failure.  Brain. 1987;  110 819-842
• 79 Eikermann M, Koch G, Gerwig M et al.. Muscle force and fatigue in patients with sepsis and multiorgan failure.  Intensive Care Med. 2006;  32 251-259
• 80 Segredo V, Caldwell J E, Matthay M A et al.. Persistent paralysis in critically ill patients after long-term administration of vecuronium.  N Engl J Med. 1992;  327 524-528
• 81 Zochodne D W, Ramsay D A, Saly V, Shelley S, Moffatt S. Acute necrotizing myopathy of intensive care: electrophysiological studies.  Muscle Nerve. 1994;  17 285-292
• 82 Davis N A, Rodgers J E, Gonzalez E R, Fowler III A A. Prolonged weakness after cisatracurium infusion: a case report.  Crit Care Med. 1998;  26 1290-1292
• 83 Young G B. Neurologic complications of systemic critical illness.  Neurol Clin. 1995;  13 645-658
• 84 Rezaiguia-Delclaux S, Lefaucheur J P, Zakkouri M, Duvoux C, Duvaldestin P, Stephan F. Severe acute polyneuropathy complicating orthotopic liver allograft failure.  Transplantation. 2002;  74 880-882
• 85 Sheth R D, Bolton C F. Neuromuscular complications of sepsis in children.  J Child Neurol. 1995;  10 346-352
• 86 Bolton C F. Sepsis and the systemic inflammatory response syndrome: neuromuscular manifestations.  Crit Care Med. 1996;  24 1408-1416
• 87 Van den Berghe G, Wilmer A, Hermans G et al.. Intensive insulin therapy in the medical ICU.  N Engl J Med. 2006;  354 449-461
• 88 van den Berghe G, Wouters P, Weekers F et al.. Intensive insulin therapy in critically ill patients.  N Engl J Med. 2001;  345 1359-1367
• 89 Bleck T P. Intensive insulin therapy reduced the incidence of neurologic complications in critically ill patients.  ACP J Club. 2006;  144 20
• 90 Bleck T P. The expanding spectrum of critical illness polyneuropathy.  Crit Care Med. 1996;  24 1282-1283
• 91 Hund E F, Fogel W, Krieger D, DeGeorgia M, Hacke W. Critical illness polyneuropathy: clinical findings and outcomes of a frequent cause of neuromuscular weaning failure.  Crit Care Med. 1996;  24 1328-1333
• 92 Gorson K C. Approach to neuromuscular disorders in the intensive care unit.  Neurocritical Care. 2005;  3 195-212
• 93 Bolton C F. AAEM minimonograph 340: clinical neurophysiology of the respiratory system.  Muscle Nerve. 1993;  16 809-818
• 94 Griffin J W, Li C Y, Ho T W et al.. Pathology of the motor-sensory axonal Guillain-Barré syndrome.  Ann Neurol. 1996;  39 17-28
• 95 Kelly B J, Matthay M A. Prevalence and severity of neurologic dysfunction in critically ill patients: influence on need for continued mechanical ventilation.  Chest. 1993;  104 1818-1824
• 96 Rich M M, Teener J W, Raps E C, Schotland D L, Bird S J. Muscle is electrically inexcitable in acute quadriplegic myopathy.  Neurology. 1996;  46 731-736
• 97 Sander H W, Golden M, Danon M J. Quadriplegic areflexic ICU illness: selective thick filament loss and normal nerve histology.  Muscle Nerve. 2002;  26 499-505
• 98 Spitzer A R, Giancarlo T, Maher L, Awerbuch G, Bowles A. Neuromuscular causes of prolonged ventilator dependency.  Muscle Nerve. 1992;  15 682-686
• 99 Zochodne D W, Ramsay D A, Saly V, Shelley S, Moffatt S. Acute necrotizing myopathy of intensive care: electrophysiological studies.  Muscle Nerve. 1994;  17 285-292