Neurology India Medknow Publications on behalf of the Neurological Society of India ISSN: 0028-3886 EISSN: 1998-4022 Vol. 53, Num. 2, 2005, pp. 206-207

Neurology India, Vol. 53, No. 2, April-June, 2005, pp. 206-207

Invited Comments

Invited Comment

Murthy J.M. K.

Department of Neurology, The Institute of Neurological Sciences, CARE Hospital, Hyderabad
Correspondence Address: Department of Neurology, The Institute of Neurological Sciences, CARE Hospital, Hyderabad, jmkmurthy@satyam.net.in

Code Number: ni05062

Related article: ni05060

Fever is frequent in patients with acute neurolgic insult admitted to neurological intensive care units (ICU).[1],[2],[3] There is growing evidence that elevated body temperature may be deleterious in this population. Fever was independently associated with a longer ICU and hospital length of stay (LOS) in a dose-dependent manner, and also with higher mortality rate, and worse outcome. The relationship between elevated body temperature and hospital LOS was significant in all diagnosis groups except spine disease, brain tumors, and subdural hematomas.[3]

The incidence of fever after supratentorial intracerebral hemorrhage (ICH) is high, especially in patients with intraventricular hemorrhage (IVH).[4] Both ICH and subarchnoid hemorrhage (SAH) increase the risk of developing of unexplained, ′central′ fever.[2],[4] The study by Diogaonkar et al .[5] in this issue of the journal confirms the same. Refractory high fever (>42°C) in the immediate aftermath of massive supratentorial or brainstem ICH is well described, and is the basic observation supporting ′central fever′ as a clinical entity.[6],[7],[8] What factors increase the risk for developing ′central fever′ in patients with ICH is not clear. In the Columbia study intraventricular catheter (IVC) placement in patients with SAH and ICH was independently associated with ′central fever.′[2] Fever is generally has been associated with IVH in ICH patients.[4] Both these observations suggest that IVH can cause ′central fever.′ The study by Diogaonkar et al .[5] demonstrates the relationship between elevated body temperature and third ventricular shift. How IVH and third ventricular shift affect hypothalamic function and cause ′central fever′ is speculative.[9] One of the possible mechanisms as suggest by Diogaonkar et al .[5] is by hypothalamic compression resulting in hypothalamic dendrites to buckle and thereby disruption temperature homeostasis. In patients with IVH it may be related to direct hemotoxic damage to thermoregulatory centers.[5]

The risk of developing fever with these risk factors, IVH and third ventricular shift, in patients with ICH is sufficiently high to warrant early active intervention to maintain normothermia and prevent fever. The impact of elevated body temperature control on outcome in patients with acute brain insult, however, has not yet been tested. There has been no prospective study of an attempt to maintain euthermia in patients with acute brain insults. Thus it remains unproven as to whether control of elevated body temperature could improve outcome or decrease hospital LOS. Conventional means of treating fever are not very effective. Acetaminophen and air-cooling blankets effectively treat elevated body temperature in less than half of the patients.[10] Recently studies showed catheter-based heat exchange system significantly improves fever reduction in NICU patients.[11] As we now have an effective tool, catheter-based heat exchange system, for treating fever in this population of patients, an outcome study is possible and should be performed.

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