Central Hyperthermia

1. A D E W I J A Y A , M D
- J U L Y 2 0 1 9 -
Central Hyperthermia

2. Outline:
 Introduction
 Clinical Manifestation
 Pathogenesis
 Diagnosis
 Management
 Summary

3. Introduction
 Fever occurs in 23% of stroke patients
 Fever in CNS disorders without evidence of infection
 Poor response to antipyretics
 33 % of fever in stroke patients
 90 % occur during first 3 days of stroke
Morales-Ortiz A, Jiménez-Pascual M, Pérez-Vicente JA, Monge-Arguiles A, Bautista-Prados J. Fever of central origin during stroke. Rev Neurol. 2001;32(12):1111–1114
Sung CY, Lee TH, Chu NS. Central hyperthermia in acute stroke. Eur Neurol. 2009;62(2):86–92

4. Clinical Manifestation
Rapid onset
Marked
fluctuation
High
temperature
Schwarz S, Häfner K, Aschoff A, Schwab S. Incidence and prognostic significance of fever following intracerebral hemorrhage. Neurology. 2000;54(2):354–361.
Sung CY, Lee TH, Chu NS. Central hyperthermia in acute stroke. Eur Neurol. 2009;62(2):86–92
Morales-Ortiz A, Jiménez-Pascual M, Pérez-Vicente JA, Monge-Arguiles A, Bautista-Prados J. Fever of central origin during stroke. Rev Neurol. 2001;32(12):1111–1114

5. Pathogenesis
 Damage or dysfunction to central fever control
centers, such as at the level of the diencephalon
 Selective loss of warm-sensitive neurons, the osmotic
changes detected by the organum vasculosum
laminae terminalis (OVLT), or the humoral changes
(progesterone, prostaglandin) modifying the firing
rate of heat sensitive neurons in the medial preoptic
nucleus (MPO) – hypothalamus
 Brainstem; brown adipose thermogenesis (BAT)
C. B. Saper, J. Lu, T. C. Chou, and J. Gooley, “The hypothalamic integrator for circadian rhythms,” Trends in Neurosciences, vol. 28, no. 3, pp. 152–157, 2005
M. R. Crompton, “Hypothalamic lesions following closed head injury,” Brain, vol. 94, no. 1, pp. 165–172, 1971. View at Publisher
M. Rango, A. Arighi, L. Airaghi, and N. Bresolin, “Central hyperthermia, brain hyperthermia and low hypothalamus temperature,” Clinical Autonomic Research, vol.
22, no. 6, pp. 299–301, 2012.
Sung CY, Lee TH, Chu NS. Central hyperthermia in acute stroke. Eur Neurol. 2009;62(2):86–92
N. Samudra and S. Figueroa, “Intractable central hyperthermia in the setting of brainstem hemorrhage,” Therapeutic Hypothermia and Temperature Management, vol.
6, no. 2, pp. 98–101, 2016.

6. Diagnosis
 (a) High fever with temperatures > 39°C within 24
hours after onset of stroke
 (b) No prior infections or fevers at least 1 week prior
to onset of stroke
 (c) Negative workup for fever of infectious origin
H. C. Lee, J. M. Kim, J. K. Lim, Y. S. Jo, and S. K. Kim, “Central hyperthermia treated with baclofen for patient with pontine hemorrhage,” Annals of Rehabilitation
Medicine, vol. 38, no. 2, pp. 269–272, 2014.

7. Management
 Multimodal approach
 Medications like bromocriptine or baclofen
 Intravascular cooling devices
 Antipyretic
Natteru, P., George, P., Bell, R., Nattanmai, P., & Newey, C. R. (2017). Central Hyperthermia Treated with Bromocriptine. Case reports in neurological medicine, 2017.

8. Bromocriptine
 Dopamine D2 agonist that acts on the corpus
striatum and the hypothalamus
 0.025 mg/kg twice daily and gradually increased to
0.05 mg/kg thrice daily
Russo RN, O’Flaherty S. Bromocriptine for the management of autonomic dysfunction after severe traumatic brain injury. J Paediatr Child Health. 2000;36(3):283–285.
Kang SH, Kim MJ, Shin IY, Park DW, Sohn JW, Yoon YK. Bromocriptine for control of hyperthermia in a patient with mixed autonomic hyperactivity after neurosurgery:
a case report. J Korean Med Sci. 2012;27(8):965–968

9. Baclofen
 GABA agonist
 Acts on the raphe nuclei and inhibits BAT which in
turn can suppress the core body temperature
 Side effects: drowsiness, tiredness, and muscle
weakness of the affected or unaffected limbs
 Dose: 30-60 mg / day
Y.-S. Huang, M.-C. Hsiao, M. Lee, Y.-C. Huang, and J.-D. Lee, “Baclofen successfully abolished prolonged central hyperthermia in a patient with basilar artery occlusion,”
Acta Neurologica Taiwanica, vol. 18, no. 2, pp. 118–122, 2009
A. Hulme, W. J. MacLennan, R. T. Ritchie, V. A. John, and P. A. Shotton, “Baclofen in the elderly stroke patient its side-effects and pharmacokinetics,” European Journal
of Clinical Pharmacology, vol. 29, no. 4, pp. 467–469, 1985.
Lee, H. C., Kim, J. M., Lim, J. K., Jo, Y. S., & Kim, S. K. (2014). Central hyperthermia treated with baclofen for patient with pontine hemorrhage. Annals of rehabilitation
medicine, 38(2), 269.

10. Summary
 Fever often occurs in CNS injury
 Mostly due to infections
 Central hyperthermia  rule out infection
 Hypothalamus; brainstem
 Multimodal approach
 Bromocriptine & baclofen