Recognition of Paroxysmal Autonomic Instability With Dystonia (PAID) in a Patient With Traumatic Brain Injury

Identification and Management of Paroxysmal Sympathetic Hyperactivity After Traumatic Brain Injury

Paroxysmal sympathetic hyperactivity (PSH) has predominantly been described after traumatic brain injury (TBI), which is associated with hyperthermia, hypertension, tachycardia, tachypnea, diaphoresis, dystonia (hypertonia or spasticity), and even motor features such as extensor/flexion posturing. Despite the pathophysiology of PSH not being completely understood, most researchers gradually agree that PSH is driven by the loss of the inhibition of excitation in the sympathetic nervous system without parasympathetic involvement. Recently, advances in the clinical and diagnostic features of PSH in TBI patients have reached a broad clinical consensus in many neurology departments. These advances should provide a more unanimous foundation for the systematic research on this clinical syndrome and its clear management. Clinically, a great deal of attention has been paid to the definition and diagnostic criteria, epidemiology and pathophysiology, symptomatic treatment, and prevention and control of secondary brain injury of PSH in TBI patients. Potential benefits of treatment for PSH may result from the three main goals: eliminating predisposing causes, mitigating excessive sympathetic outflow, and supportive therapy. However, individual pathophysiological differences, therapeutic responses and outcomes, and precision medicine approaches to PSH management are varied and inconsistent between studies. Further, many potential therapeutic drugs might suppress manifestations of PSH in the process of TBI treatment. The purpose of this review is to present current and comprehensive studies of the identification of PSH after TBI in the early stage and provide a framework for symptomatic management of TBI patients with PSH.

Paroxysmal Sympathetic Hyperactivity After Severe Traumatic Brain Injury in Children: Prevalence, Risk Factors, and Outcome

OBJECTIVE

To describe paroxysmal sympathetic hyperactivity in pediatric patients with severe traumatic brain injury using the new consensus definition, the risk factors associated with developing paroxysmal sympathetic hyperactivity, and the outcomes associated with paroxysmal sympathetic hyperactivity.

DESIGN

Retrospective cohort study.

SETTING

Academic children's hospital PICU.

PATIENTS

All pediatric patients more than 1 month and less than 18 years old with severe traumatic brain injury between 2000 and 2016. We excluded patients if they had a history of five possible confounders for paroxysmal sympathetic hyperactivity diagnosis or if they died within 24 hours of admission for traumatic brain injury.

MEASUREMENTS AND MAIN RESULTS

Our primary outcome was PICU mortality. One hundred seventy-nine patients met inclusion criteria. Thirty-six patients (20%) had at least eight criteria and therefore met classification of "likelihood of paroxysmal sympathetic hyperactivity." Older age was the only factor independently associated with developing paroxysmal sympathetic hyperactivity (odds ratio, 1.08; 95% CI, 1.00-1.16). PICU mortality was significantly lower for those with paroxysmal sympathetic hyperactivity compared with those without paroxysmal sympathetic hyperactivity (odds ratio, 0.08; 95% CI, 0.01-0.52), but PICU length of stay was greater in those with paroxysmal sympathetic hyperactivity (odds ratio, 4.36; 95% CI, 2.94-5.78), and discharge to an acute care or rehabilitation setting versus home was higher in those with paroxysmal sympathetic hyperactivity (odds ratio, 5.59; 95% CI, 1.26-24.84; odds ratio, 5.39; 95% CI, 1.87-15.57, respectively). When paroxysmal sympathetic hyperactivity was diagnosed in the first week of admission, it was not associated with discharge disposition.

CONCLUSIONS

Our study suggests that the rate of paroxysmal sympathetic hyperactivity in patients with severe traumatic brain injury is higher than previously reported. Older age was associated with an increased risk for developing paroxysmal sympathetic hyperactivity, but severity of the trauma and the brain injury were not. For survivors of severe traumatic brain injury beyond 24 hours who developed paroxysmal sympathetic hyperactivity, there was a lower PICU mortality but also greater PICU length of stay and a lower likelihood of discharge home from the admitting hospital, suggesting that functional outcome in survivors with paroxysmal sympathetic hyperactivity is worse than survivors without paroxysmal sympathetic hyperactivity.

Diagnosis and Management of Patients with Paroxysmal Sympathetic Hyperactivity following Acute Brain Injuries Using a Consensus-Based Diagnostic Tool: A Single Institutional Case Series

Paroxysmal sympathetic hyperactivity (PSH) is a distinct syndrome of episodic sympathetic hyperactivities following severe acquired brain injury, characterized by paroxysmal transient fever, tachycardia, hypertension, tachypnea, excessive diaphoresis and specific posturing. PSH remains to be an under-recognized condition with a diagnostic pitfall especially in the intensive care unit (ICU) settings due to the high prevalence of concomitant diseases that mimic PSH. A consensus set of diagnostic criteria named PSH-Assessment Measure (PSH-AM) has been developed recently, which is consisted of two components: a diagnosis likelihood tool derived from clinical characteristics of PSH, and a clinical feature scale assigned to the severity of each sympathetic hyperactivity. We herein present a case series of patients with PSH who were diagnosed and followed by using PSH-AM in our tertiary institutional medical and surgical ICU between April 2015 and March 2017 in order to evaluate the clinical efficacy of PSH-AM. Among 394 survivors of 521 patients admitted with acquired brain injury defined as acute brain injury at all levels of severity regardless of the presence of altered consciousness, including traumatic brain injury, stroke, infectious disease, and encephalopathy, 6 patients (1.5%) were diagnosed as PSH by using PSH-AM. PSH-AM served as a useful scoring system for early objective diagnosis, assessment of severity, and serial evaluation of treatment efficacy in the management of PSH in the ICU settings. In conclusion, critical care clinicians should consider the possibility of PSH and can use PSH-AM as a useful diagnostic and guiding tool in the management of PSH.

Paroxysmal Sympathetic Hyperactivity in Children: An Exploratory Evaluation of Nursing Interventions

BACKGROUND

Paroxysmal sympathetic hyperactivity (PSH) produces symptoms of autonomic instability and muscle over-activity; however, the majority of nursing interventions used in clinical practice are anecdotal and not evidenced based.

OBJECTIVE

The primary objective was to report nursing documentation of PSH events, and to describe the clinical nursing interventions and care provided to children who have suffered a severe brain injury and are exhibiting PSH. The secondary objective was to demonstrate how the Symptom Management Theory (SMT) can serve as a framework for research related to brain injury and PSH.

METHODOLOGY

The study consisted of a retrospective chart review of nursing progress notes using direct content analysis. The nested sample of ten randomly selected charts was chosen from a larger quantitative study of 83 children who had suffered severe brain injuries with and without PSH. Textual analysis of verbatim nursing progress notes was used to describe nursing interventions that were used and documented for this patient population.

RESULTS

The priority nursing interventions to manage these symptoms included medication administration, facilitation of family presence, and strategies to target auditory, tactile, and visual stimuli. The sample received different individual interventions for PSH. Additionally, individual subjects demonstrated different patterns of interventions.

IMPLICATIONS

While tactile interventions were documented most frequently, there was not a uniform approach to interventions. The SMT can be useful to provide a framework that organizes and tests clinical care and management of PSH strategies.

Paroxysmal sympathetic hyperactivity: Autonomic instability and muscle over-activity following severe brain injury

BACKGROUND

Children who suffer from moderate-to-severe brain injury can develop a complicating phenomenon known as paroxysmal sympathetic hyperactivity (PSH), characterized by autonomic instability and identified clinically as a cluster of symptoms that can include recurrent fever without a source of infection, hypertension, tachycardia, tachypnea, agitation, diaphoresis and dystonia. Studies with adults have demonstrated that this cluster of symptoms is associated with poorer clinical outcomes (prolonged hospitalizations, poorer cognitive and motor function). However, there have been limited studies in children with PSH.

OBJECTIVE

To present a literature review regarding PSH following severe brain injury and highlight research needs in children with PSH.

METHODOLOGY

Electronic databases (CINAHL, Ovid Medline, Web of Science and Google Scholar) were searched.

RESULTS

Thirty-one research articles met the criteria for inclusion. Several themes emerged regarding the phenomenon of interest during the review: nomenclature, symptoms, management and differences between children and adults.

IMPLICATIONS

The majority of the research regarding PSH following severe brain injury has been descriptive in nature. Few studies, however, have explored PSH in children with brain injury; therefore, little is known about whether the outcomes of children with PSH are different and, if so, in what ways.

Paroxysmal Sympathetic Hyperactivity in a Child with Tuberculous Meningitis A Case Study and Review of Related Literature

A one-year old boy was admitted to hospital for lethargy and vomiting over three days. Neurological examination revealed abnormalities. Cerebrospinal fluid examination showed evidence of meningitis. A purified protein derivative (PPD) test, T-SPOT.TB and radiological examination indicated tuberculous meningitis. During treatment, the child developed hypertension, sinus tachycardia, tachypnoea, dystonia and high fever. These episodes improved after administration of propranolol, artane and clonazepam. Paroxysmal sympathetic hyperactivity is a rare manifestation of tuberculous meningitis. Early detection is very important as it can avoid diagnostic errors and overtreatment.

Alternating hemidystonia following traumatic brain injury as an unusual presentation of paroxysmal autonomic instability with dystonia syndrome

A 20-year-old man presented to the neurotrauma intensive care unit following blunt head injury. MRI revealed subarachnoid haemorrhage and multiple intraparenchymal haemorrhages suggesting severe brain injury. During recovery, the patient displayed intermittent episodes of alternating hemibody spasms with decerebrate/decorticate dystonic posturing. Episodes presented with autonomic dysregulation including hyperthermia, diaphoresis, tachypnoea, tachycardia and hypertension. Concern for seizure activity prompted simultaneous video monitoring and EEG testing. Results were without epileptiform activity suggesting against seizure as cause for alternating hemibody spasms. Paroxysmal autonomic instability with dystonia (PAID) was considered despite the unusual presentation. Intravenous hydromorphone was used for treatment, which relieved symptoms of autonomic dysregulation and dystonic posturing. PAID syndrome was diagnosed based on presentation with intermittent episodes of dystonia, autonomic dysregulation, absence of epileptiform activity and rapid response to opioid treatment. This case illustrates the clinical variability of this uncommon syndrome because alternating hemidystonia as main manifestation has not been previously described.

Prolonged paroxysmal sympathetic storming associated with spontaneous subarachnoid hemorrhage

Paroxysmal sympathetic storming (PSS) is a rare disorder characterized by acute onset of nonstimulated tachycardia, hypertension, tachypnea, hyperthermia, external posturing, and diaphoresis. It is most frequently associated with severe traumatic brain injuries and has been reported in intracranial tumors, hydrocephalous, severe hypoxic brain injury, and intracerebral hemorrhage. Although excessive release of catecholamine and therefore increased sympathetic activities have been reported in subarachnoid hemorrhage (SAH), there is no descriptive report of PSS primarily caused by spontaneous SAH up to date. Here, we report a case of prolonged PSS in a patient with spontaneous subarachnoid hemorrhage and consequent vasospasm. The sympathetic storming started shortly after patient was rewarmed from hypothermia protocol and symptoms responded to Labetalol, but intermittent recurrence did not resolve until 3 weeks later with treatment involving Midazolam, Fentanyl, Dexmedetomidine, Propofol, Bromocriptine, and minimizing frequency of neurological and vital checks. In conclusion, prolonged sympathetic storming can also be caused by spontaneous SAH. In this case, vasospasm might be a precipitating factor. Paralytics and hypothermia could mask the manifestations of PSS. The treatment of the refractory case will need both timely adjustment of medications and minimization of exogenous stressors or stimuli.

Paroxysmal autonomic instability with dystonia after pneumococcal meningoencephalitis

Streptococcus pneumoniae is a common cause of bacterial meningitis, frequently resulting in severe neurological impairment. A seven-month-old child presenting with Streptococcus pneumoniae meningoencephalitis developed right basal ganglia and hypothalamic infarctions. Daily episodes of agitation, hypertension, tachycardia, diaphoresis, hyperthermia, and decerebrate posturing were observed. The diagnosis of paroxysmal autonomic instability with dystonia was established. The patient responded to clonidine, baclofen, and benzodiazepines. Although this entity has been reported in association with traumatic brain injury, and as a sequel to some nervous system infections, this is the first case, to our knowledge, associated with pneumococcal meningoencephalitis.

Sympathetic storming in a patient with intracranial basal ganglia hemorrhage

Neurologic deficits and medical complications are common sequelae after intracranial hemorrhage. Among the medical complications, sympathetic storming is relatively rare. We describe a case of a patient with an acute right basal ganglia hemorrhage. During the patient's hospital course, he developed tachypnea, diaphoresis, hypertension, hyperthermia, and tachycardia for three consecutive days. A complete laboratory work-up and imaging studies were unremarkable for infectious etiology, new intracranial hemorrhage, and deep vein thrombosis. The patient was diagnosed with sympathetic storming, a relatively uncommon cause of these symptoms. The storming was secondary to a kinked Foley catheter, and subsequent placement of a new catheter resulted in the resolution of his symptoms.