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Thread: Dr. Young or SCI nurses,

  1. #1

    Dr. Young or SCI nurses,

    Have people died from AD?
    If so, is it from the high blood pressure? Would that be a stroke?
    Also, how high is high (BP)?
    Thank You,

  2. #2
    Yes, there have been deaths due to AD. I have seen this occur in a number of people with SCI over the years of my practice, in addition to the cases reported in the literature. The most common cause of death is stroke, usually intracranial hemorrhage, but other causes can be ruptured aneurysms any place in the body, cardiac arrythmia, or myocardio infarction (heart attack).

    In addition, serious conditions other than death have been documented. This includes bleeding into the eyes (resulting in blindness), bleeding into the kidneys (resulting in renal failure), and non-fatal strokes and heart attacks. These have occured with systolic blood pressures as low as 160, but blood pressures as high as 300 systolic have been recorded.

    The Consortium for Spinal Cord Medicine clinical practice guidelines on the management of AD state that the person should be considered to have AD if they have symptoms and a systolic blood pressure 40 mm. Hg. or higher over their usual (baseline) systolic pressure, and medication to control the blood pressure should be considered if the systolic pressure exceeds 150 mm. Hg.


  3. #3
    Don't forget seizures which have also been documented in the literature.

  4. #4
    Yup it sure can. When I was taken to the ER because of severe pain, the ER doctor (thank God Dr. Bosco recognized it), told me to get to the ER by ambulance the next time things ever progress to that point again. I did not realize what was happening because the pain was so severe, and I delayed, trying to take pain meds to control the pain. He was really worried that I had an anurism from it and checked me out carefully. That was pretty scarey especially when he told me it could cause a stroke or anurism possably leading to death.

    Yes, carry a card for paramedics and other medical staff, and do not mess around if you start to feel the symptoms. Check for irritations, blocked catheter or very ful bladder, full bowel, or the beginnings of pressure sores. Then if you cannot control what is causing it, do not wait till your bp is up to ?/217, like I did, and endanger yourself. Croaking or stroking out is not worth it.

  5. #5
    AD can cause death but it often depends on the presence of cardiac arrythmias and other risks. Blood pressure needs to be controlled to some extent. However, I know some people who have tolerated almost daily mild to moderate AD (with systolic blood pressures under 200 mm Hg) without cardiac problems of stroke. I just did a medline search for mortality with AD but unfortunately I was unable to find a well-planned prospective study of AD and complications. However, there are a lot of studies suggesting that uncontrolled AD can caus stroke and death. Here are some comments:

    • One animal study is of interest. Gris, et al. (2005) reported the methylprednisolone treatment reduced autonomic dysreflexia by about 50% in the 2 weeks after spinal cord injury but that anti-CD11d antibody had longer effects.
    • Joint degeneration can cause AD. Mohit, et al. (2005) reported that charcot spinal arthropathy can be a powerful trigger for induction of autonomic dysreflexia.
    • Intracerebral hemorrhage can occur in patients with incomplete spinal cord injury. Pan, et al. (2005) described a case of AD in a young person with an incomplete C8 injury that led to brain hemorrhage.
    • Kutzenberger, et al. (2005) did 464 cases of anterior root stimulation for bladder after sacral deafferentation in patients with spinal cord injury and hyperreflexia. He reports that it virtually eliminated AD.
    • Tolbert, et al (2004) did ambulatory blood pressure monitoring in people with chronic spinal cord injury, finding that this showed blood pressure changes that were not detected with intermittent blood pressure monitoring.
    • Assadi, et al. (2004) reported a young man who had severe hypertension that could not be resolved by drugs but resolved immediately upon decompression of the bladder.

    So, in summary, AD can cause severe hypertension that can cause stroke and cardiac problems. The best way to reduce AD is to eliminate the cause.


    1. Collins HL, Rodenbaugh DW and DiCarlo SE (2006). Spinal cord injury alters cardiac electrophysiology and increases the susceptibility to ventricular arrhythmias. Prog Brain Res 152: 275-88. The autonomic nervous system modulates cardiac electrophysiology and abnormalities of autonomic function are known to increase the risk of ventricular arrhythmias. The abnormal and unstable autonomic control of the cardiovascular system following spinal cord injury also is well known. For example, individuals with mid-thoracic spinal cord injury have elevated resting heart rates, increased blood pressure variability, episodic bouts of life-threatening hypertension as part of a condition termed autonomic dysreflexia, and elevated sympathetic activity above the level of the lesion. Furthermore, cardiovascular morbidity and mortality are high in individuals with spinal cord injuries due to a relatively sedentary lifestyle and higher prevalence of other cardiovascular risk factors, including obesity and diabetes. Therefore, spinal cord injury may alter cardiac electrophysiology and increase the risk for ventricular arrhythmias. In this chapter, we discuss how the autonomic changes associated with cord injury can influence cardiac electrophysiology and the susceptibility to ventricular arrhythmias. Department of Physiology, Wayne State University School of Medicine, Detroit, MI 48201, USA.
    2. Valles M, Benito J, Portell E and Vidal J (2005). Cerebral hemorrhage due to autonomic dysreflexia in a spinal cord injury patient. Spinal Cord 43: 738-40. STUDY DESIGN: Case report. OBJECTIVE: To report an uncommon case of cerebral hemorrhage due to autonomic dysreflexia (AD) in a spinal cord injury (SCI) patient. SETTING: Institut Guttmann, Neurorehabilitation Hospital in Barcelona, Spain. CASE REPORT: An SCI patient developed AD due to urinary tract infection after surgery for a pressure sore. The hypertension was difficult to control and the case progressed to hypertensive encephalopathy. MRI of the brain was performed showing a hemorrhagic lesion on the left occipital area. The hypertension was finally controlled and the neurological status improved although with some cognitive deficits. CONCLUSION: This is an uncommon case of cerebral hemorrhage due to AD, showing the importance of an adequate diagnosis and treatment of AD to avoid this life-threatening complication. Spinal Cord Injury Unit, Institut Guttmann, Barcelona, Spain.
    3. Cosman BC and Vu TT (2005). Lidocaine anal block limits autonomic dysreflexia during anorectal procedures in spinal cord injury: a randomized, double-blind, placebo-controlled trial. Dis Colon Rectum 48: 1556-61. PURPOSE: Autonomic dysreflexia is a common and potentially dangerous hypertensive response to stimulation below the level of injury that occurs in patients with spinal cord injury at T6 or above. Rectosigmoid distention and anal manipulation are among the stimuli that may precipitate autonomic dysreflexia. Instillation of topical local anesthetic into the rectum is the recommended prophylaxis against autonomic dysreflexia of anorectal origin. However, a previous randomized, double-blind, placebo-controlled trial showed that topical lidocaine in the rectum does not blunt the autonomic dysreflexia response to anorectal procedures. The purpose of this study was to determine whether lidocaine anal sphincter block would be effective in limiting anorectal procedure-associated autonomic dysreflexia. METHODS: We enrolled patients with chronic, complete spinal cord injury above T6, who were having anorectal procedures (flexible sigmoidoscopy and/or anoscopic hemorrhoid ligation). In a double-blind fashion, patients were randomized for intersphincteric anal block with 1 percent lidocaine or normal saline (placebo) before the procedure. Blood pressure was measured before, during, and after the block and procedure. RESULTS: Thirteen patients received lidocaine, and 13 received placebo. The groups were similar in age, level of injury, duration of spinal cord injury, type of procedure, and procedure duration. The mean maximal systolic blood pressure increase for the lidocaine group was 22 +/- 14 mmHg, significantly lower than the placebo group's 47 +/- 31 mmHg (P = 0.01). CONCLUSIONS: Lidocaine anal block significantly limits the autonomic dysreflexia response in susceptible patients undergoing anorectal procedures. Surgical Service, VA San Diego Healthcare System, San Diego, California 92161-0002, USA.
    4. Jacob C, Thwaini A, Rao A, Arya N, Shergill IS and Patel HR (2005). Autonomic dysreflexia: the forgotten medical emergency. Hosp Med 66: 294-6. Autonomic dysreflexia (AD) is a potentially dangerous complication of spinal cord injury (SCI). In AD, an individual's blood pressure may rise to dangerous levels and, if not treated, can lead to stroke and possibly death. All medical personnel, especially those interacting with SCI patients, must have a good understanding of its aetiology, complications and emergency management. Department of Urology, Bradford Royal Infirmary, Bradford.
    5. Gris D, Marsh DR, Dekaban GA and Weaver LC (2005). Comparison of effects of methylprednisolone and anti-CD11d antibody treatments on autonomic dysreflexia after spinal cord injury. Exp Neurol 194: 541-9. Autonomic dysreflexia is a condition of episodic hypertension that develops after spinal cord injury (SCI). We previously showed that a two-day anti-inflammatory treatment with an anti-CD11d integrin monoclonal antibody (mAb), soon after SCI in rats, reduced the magnitude of dysreflexia for at least 6 weeks. Effects of methylprednisolone (MP), a commonly used neuroprotective treatment for SCI, on dysreflexia have never been examined. We compared the effects of a 2-day MP treatment and/or the anti-CD11d mAb on autonomic dysreflexia, elicited by colon distension, after clip-compression SCI at the 4th thoracic segment (T4) in rats. We assessed the effects of each treatment on the size of the calcitonin gene-related peptide (CGRP)-immunoreactive afferent arbour in the dorsal horn, as changes in this arbour can correlate with the development of dysreflexia. MP reduced autonomic dysreflexia by approximately 50% at 2 weeks after SCI, but this effect was lost by 6 weeks. At 2 weeks, the combined effects of MP and the mAb were not additive, reducing dysreflexia by approximately 50%. Neither MP nor the mAb treatment altered the area of CGRP-immunoreactive fibres in the lumbar cord, the crucial input region for dysreflexia initiated by colon distension. However, both treatments led to increased fibre areas in the T9 segment, correlated with greater tissue integrity and smaller lesions, delineated by inflammatory cells. In summary, MP only temporarily decreases autonomic dysreflexia after SCI. The early beneficial effects of both treatments on dysreflexia do not relate to changes in the CGRP-immunoreactive afferent arbour but may correlate with decreased lesion progression. Spinal Cord Injury Team, Laboratory of Spinal Cord Injury, BioTherapeutics Research Group, Robarts Research Institute and Graduate Program in Neuroscience, University of Western Ontario, 100 Perth Drive, London, Ontario, Canada N6A 5K8.
    6. Kutzenberger J, Domurath B and Sauerwein D (2005). Spastic bladder and spinal cord injury: seventeen years of experience with sacral deafferentation and implantation of an anterior root stimulator. Artif Organs 29: 239-41. INTRODUCTION: Spinal cord injured patients with a suprasacral lesion usually develop a spastic bladder. The hyperreflexia of the detrusor and the external sphincter causes incontinence and threatens those patients with recurrent urinary tract infections (UTI), renal failure, and autonomic dysreflexia. All of these severe disturbances may be well managed by sacral deafferentation (SDAF) and implantation of an anterior root stimulator. MATERIAL AND METHOD: Between September 1986 to December 2002, 464 paraplegic patients (220 female, 244 male) received a SDAF-SARS. Almost exclusively the SDAF was done intradurally, which means with one operation field there can be done two steps (SDAF and SARS). RESULTS: 440 patients have a follow-up with 6.6 years (at least > 6 months-17 years). The complete deafferentation was successful in 94.1%. A total of 420 paraplegics may use the SARS for voiding (frequency 4.7 per day) and 401 use it for defecation (frequency 4.9 per week). Continence was achieved in 364 patients (83%). UTI declined from 6.3 per year preoperatively to 1.2 per year postoperatively. Kidney function presented stable. Early complications were 6 CSF leaks, 5 implant infections. Late complications with receiver or cable failures made us do surgical repairs in 34 paraplegics. A step-by-step program for trouble-shooting differentiates implant failure and myogenic or neurogenic failure. CONCLUSION: SDAF is able to restore the reservoir function of the urinary bladder and to achieve continence. Autonomic dysreflexia disappeared in most of the cases. By means of an accurate adjustment of stimulation parameters it is possible to accomplish low resistance micturition. The microsurgical technique requires an intensive education. One has to be able to manage late implant complications. Clinic for Neuro-Urology, Werner-Wicker Hospital, Bad Wildungen, Germany.
    7. Mohit AA, Mirza S, James J and Goodkin R (2005). Charcot arthropathy in relation to autonomic dysreflexia in spinal cord injury: case report and review of the literature. J Neurosurg Spine 2: 476-80. Charcot spinal arthropathy has been described as a late complication of spinal cord injury. In patients with these injuries in whom the spine below the level of injury is insensate, joint trauma can progress until spinal instability ensues. The authors describe the case of a 50-year-old man with complete C-8 tetraplegia who experienced a 4-month history of episodic severe headaches, profuse sweating over his face and arms, and episodic severe hypertension in addition to a "grinding" sensation in the lower back. Charcot arthropathy at the T11-12 levels with pathological mobility was demonstrated on neuroimaging. Intraoperatively, a complete spinal cord transection was identified. Anterior and posterior thoracolumbar fusion across the mobile segment resulted in complete amelioration of signs and symptoms of autonomic dysreflexia. This entity, a common condition in the setting of spinal cord injury, has many triggers. Definitive treatment is targeted at the removal of the underlying cause. As demonstrated here, Charcot spinal arthropathy can act as a powerful trigger for induction of autonomic dysreflexia. Treatment of the associated spinal instability resulted in eradication of all signs and symptoms of the dysreflexia. Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington 98104-2499, USA.
    8. Sheel AW, Krassioukov AV, Inglis JT and Elliott SL (2005). Autonomic dysreflexia during sperm retrieval in spinal cord injury: influence of lesion level and sildenafil citrate. J Appl Physiol 99: 53-8. Autonomic dysreflexia (AD) can occur during penile vibratory stimulation in men with spinal cord injury, but this is variable, and the association with lesion level is unclear. The purpose of this study was to characterize the cardiovascular responses to penile vibratory stimulation in men with spinal cord injury. We hypothesized that those with cervical injuries would demonstrate a greater degree of AD compared with men with thoracic injuries. We also questioned whether the rise in blood pressure could be attenuated by sildenafil citrate. Participants were classified as having cervical (n = 8) or thoracic (n = 5) injuries. While in a supine position, subjects were instrumented with an ECG, and arterial blood pressure was determined beat by beat. Subjects reported to the laboratory twice and received an oral dose of sildenafil citrate (25-100 mg) or no medication. Penile vibratory stimulation was performed using a handheld vibrator to the point of ejaculation. At ejaculation during the nonmedicated trials, the cervical group had a significant decrease in heart rate (-5-10 beats/min) and increase in mean arterial blood pressure (+70-90 mmHg) relative to resting conditions, whereas the thoracic group had significant increases in both heart rate (+8-15 beats/min) and mean arterial pressure (+25-30 mmHg). Sildenafil citrate had no effect on the change in heart rate or mean arterial pressure in either group. In summary, men with cervical injuries had more pronounced AD during penile vibratory stimulation than men with thoracic injuries. Administration of sildenafil citrate had no effect on heart rate or blood pressure during penile vibratory stimulation in men with spinal cord injury. International Collaboration on Repair Discoveries, and School of Human Kinetics, The Univ. of British Columbia, 210-6081 Univ. Blvd., Vancouver, BC, Canada V6T-1Z1.
    9. Pan SL, Wang YH, Lin HL, Chang CW, Wu TY and Hsieh ET (2005). Intracerebral hemorrhage secondary to autonomic dysreflexia in a young person with incomplete C8 tetraplegia: A case report. Arch Phys Med Rehabil 86: 591-3. Intracerebral hemorrhage is an unusual complication of autonomic dysreflexia and can be fatal if massive bleeding occurs with brain herniation. We report the case of a man in his midthirties with incomplete tetraplegia who suffered right putaminal hemorrhage during an episode of autonomic dysreflexia. Prompt recognition and removal of the triggering factors of autonomic dysreflexia quickly brought his blood pressure under control and the patient had a favorable functional outcome after rehabilitation. A review of the literature suggests that the location of hemorrhage in autonomic dysreflexia-induced cases is similar to that in the general population. The most common triggering factors are bladder distension in men and labor induction in women. Hemorrhagic stroke can also occur in patients with incomplete spinal cord injury (SCI) who develop autonomic dysreflexia. The role of sympathetic skin response examination is also discussed. This life-threatening complication should be kept in mind in the case of people with SCI. Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan.
    10. Assadi F, Czech K and Palmisano JL (2004). Autonomic dysreflexia manifested by severe hypertension. Med Sci Monit 10: CS77-9. BACKGROUND: Autonomic dysreflexia (AD) is a sudden and exaggerated autonomic response to stimuli in patients with spinal cord injuries or dysfunction above the splanchnic sympathetic outflow (T5-T6). Hypertension is a relatively common manifestation of AD. CASE REPORT: We describe a case of a young man with T4-T6 spinal cord tumor who developed severe hypertension before any other clinical feature of AD, leading to a subsequent clinical evaluation and the correct diagnosis. Treatment with labetalol was only partially successful in controlling the elevated blood pressure. Hypertension resolved immediately after bladder decompression. CONCLUSIONS: AD manifested by severe hypertension is uncommon. Bladder decompression appears to be safe and effective for management of hypertension in patients with AD. Department of Pediatrics, Section of Nephrology, Rush University Medical College, Chicago, IL 60612, USA.
    11. Bravo G, Guizar-Sahagun G, Ibarra A, Centurion D and Villalon CM (2004). Cardiovascular alterations after spinal cord injury: an overview. Curr Med Chem Cardiovasc Hematol Agents 2: 133-48. The recent developments in the management of spinal cord injury (SCI) have led to a reduction in mortality and in the consequences, resulting from incomplete spinal cord damage in those who survive. In this respect, it is noteworthy that SCI not only results in paraplegia or tetraplegia, but also in systemic, cardiovascular and metabolic alterations secondary to autonomic dysfunction. After SCI there is a decrease in sympathetic discharge and an increase in parasympathetic drive, resulting in profound changes in arterial blood pressure and heart rate. When SCI is induced in experimental animals, an immediate hypotension occurs (acute phase) which has been attributed to an autonomic imbalance involving a predominance of parasympathetic activity. Subsequently, an episodic hypertension may develop (chronic phase) as a part of a condition denominated autonomic dysreflexia. This hypertension is caused by afferent stimulation below the level of injury and can be so severe that sometimes may lead to cerebral haemorrhage, seizures, and death. In the light of the above lines of evidence, experimental SCI may provide an ideal model to study the nature of cardiovascular mechanisms following traumatic injury. Thus, the present review will deal with an update of the possible cardiovascular complications associated to SCI (including spinal shock, autonomic dysreflexia, deep venous thrombosis, and risk for coronary heart disease). This will be discussed within the context of the development of drugs with potential therapeutic usefulness in the acute and chronic stages of SCI. Departamento de Farmacobiologia, CINVESTAV-IPN, Czda. de los Tenorios 235, Col. Granjas Coapa, Deleg. Tlalpan, 14330 Mexico DF, Mexico.
    12. Tolbert G and Tuck ML (2004). Ambulatory blood pressure monitoring in persons with chronic spinal cord injury. J Spinal Cord Med 27: 476-80. BACKGROUND: Hypertension alone or in the presence of autonomic dysreflexia (AD) may be underdiagnosed and consequently mismanaged in people with chronic spinal cord injury (SCI). Blood pressure (BP) derangements caused by AD are characterized by labile BP, in addition to episodic hypertension. Consequently, random BP readings often prove insufficient, which makes traditional outpatient evaluation and management suboptimal. Because elevated BP is common to essential hypertension (EH) and AD, distinction between the 2 entities proves challenging. The distinction is imperative because the treatments differ. Conventional BP monitoring in the office may miss labile BP patterns and episodic BP elevations. Ambulatory BP monitoring (ABPM) is used in the general population to improve the diagnosis and management of hypertension. ABPM provides the average BP level, circadian rhythm, and short-term BP variability. There is a paucity of ABPM studies in persons with SCI. OBJECTIVE: To explore the role of ABPM in individuals with SCI. METHODS: This study is a case description and detailed analysis of the use of ambulatory blood pressure monitoring (ABPM) in 3 persons with chronic SCI. RESULTS: Three cases were identified in which the diagnosis of autonomic dysreflexia, exaggerated blood pressure variability and disruption of circadian blood pressure pattern was delayed using conventional blood pressure evaluation. ABPM aided in diagnosis by providing the average blood pressure level, circadian rhythm and short-term BP variability. CONCLUSION: Because conventional office BP monitoring may miss labile BP patterns and episodic BP elevations, it is limited in the SCI population. ABPM may improve the outpatient management of blood pressure abnormalities in individuals with chronic SCI by clarifying mechanisms and patterns of BP in this patient population. VA Greater Los Angeles Healthcare System, Sepulveda, California, USA.
    13. Curtin CM, Gater DR and Chung KC (2003). Autonomic dysreflexia: a plastic surgery primer. Ann Plast Surg 51: 325-9. Plastic surgeons are integral to the management team for patients with spinal cord injuries, with responsibilities including pressure sore management and upper extremity reconstruction. Injury to the spinal cord profoundly disrupts the body's ability to maintain homeostasis. In particular, the autonomic system can become unregulated, resulting in a massive sympathetic discharge called autonomic dysreflexia. Autonomic dysreflexia occurs in the majority of patients with injuries above the sixth thoracic vertebra and causes sudden, severe hypertension. If left untreated, autonomic dysreflexia can result in stroke or death. Because this syndrome causes morbidity and mortality, it is crucial for plastic surgeons to be able to recognize and treat autonomic dysreflexia. This article reviews the etiology, symptoms, and treatment of this syndrome. Robert Wood Johnson Clinical Scholars Program, The University of Michigan Medical Center, 6312 Medical Science Building 1, 1150 W. Medical Center Drive, Ann Arbor, MI 48109-0604, USA.
    14. Braddom RL and Rocco JF (1991). Autonomic dysreflexia. A survey of current treatment. Am J Phys Med Rehabil 70: 234-41. Autonomic dysreflexia (AD) is a syndrome that often occurs in patients with spinal cord injuries above T-6 and can have life-threatening results if not properly managed. The hypertension associated with AD can cause a great deal of morbidity and mortality, requiring quick and effective blood pressure reduction. Both pharmacologic and nonpharmacologic methods are used to prevent or alleviate the symptoms associated with an acute episode of AD. We found that current literature is lacking in controlled, prospective, randomized studies comparing the efficacy of various medications used in the treatment of AD. We conducted a nationwide survey to determine the consensus among clinicians concerning the management of AD. The survey was designed to determine the current clinical status of AD, to assess methods of treatment being used and to summarize and give a rationale for the drugs most commonly prescribed. Finally, a suggestion for a wallet-sized card briefly outlining effective treatments of AD in an emergency situation is included. Results indicate that most clinicians feel that after nonpharmacologic measures have failed, antihypertensive medication is useful in controlling the symptoms of AD while the inciting cause is being found and treated. Agents used most frequently include, but are not limited to, nifedipine, phenoxybenzamine, prazosin, mecamylamine and nitrates. Moss Rehabilitation Hospital, Philadelphia, Pennsylvania.
    15. Jane MJ, Freehafer AA, Hazel C, Lindan R and Joiner E (1982). Autonomic dysreflexia. A cause of morbidity and mortality in orthopedic patients with spinal cord injury. Clin Orthop Relat Res 151-4.
    16. Kursh ED, Freehafer A and Persky L (1977). Complications of autonomic dysreflexia. J Urol 118: 70-2. Autonomic dysreflexia can be a life-threatening problem if not promptly recognized and treated. Since the most common cause is bladder distension it is essential that the urologist be familiar with this syndrome. Several patients with serious complications owing to autonomic dysreflexia, including 1 mortality, are presented. The complications of autonomic dysreflexia result from a sudden marked rise in blood pressure, which may be severe enough to rupture single or multiple cerebral blood vessels or lead to a considerable increase in intracranial pressure. The neurophysiology, clinical features and therapeutic measures are discussed.

  6. #6
    It's often mentioned that if you're prone to AD, carry a card indicating this issue. What should be written on this card?

  7. #7
    You guys are all amazing.
    This is why I love this site.
    Thank you so much,

  8. #8
    Senior Member keps's Avatar
    Join Date
    May 2005
    United Kingdom
    Quote Originally Posted by dan_nc
    It's often mentioned that if you're prone to AD, carry a card indicating this issue. What should be written on this card?
    When I left the spinal unit, I was given some cards, one of which explained symptoms and causes of AD, and what to do to treat it.
    I always carry these cards whenever I go out.

  9. #9

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