Diagnosis and Treatment of Paroxysmal Sympathetic Hyperactivity in Medical ICU, University of Gondar Hospital, Northwest Ethiopia: A Case Report

Paroxysmal Sympathetic Hyperactivity After Acquired Brain Injury: An Integrative Review of Diagnostic and Management Challenges

Paroxysmal sympathetic hyperactivity (PSH) mainly occurs after acquired brain injury (ABI) and often presents with high fever, hypertension, tachycardia, tachypnea, sweating, and dystonia (increased muscle tone or spasticity). The pathophysiological mechanisms of PSH are not fully understood. Currently, there are several views: (1) disconnection theory, (2) excitatory/inhibitory ratio, (3) neuroendocrine function, and (4) neutrophil extracellular traps. Early diagnosis of PSH remains difficult, given the low specificity of its diagnostic tools and unclear pathogenesis. According to updated case analyses in recent years, PSH is now more commonly observed in patients with stroke, with tachycardia and hypertension as the main clinical manifestations, which is not fully consistent with previous data. To date, the PSH Assessment Measure tool is optimal for the early identification of PSH and stratification of symptom severity. Clinical strategies for the management of PSH are divided into three main points: (1) reduction of stimulation, (2) reduction of sympathetic excitatory afferents, and (3) inhibition of the effects of sympathetic hyperactivity on target organs. However, use of drugs and standards have not yet been harmonized. Further investigation on the relationship between PSH severity and long-term neurological prognosis in patients with ABI is required. This review aimed to determine the diagnostic and management challenges encountered in PSH after ABI.

Paroxysmal Sympathetic Hyperactivity in Stroke

OBJECTIVE

Paroxysmal sympathetic hyperactivity (PSH) is a life-threatening neurological emergency associated with severe brain injury. Stroke-related PSH, particularly post-aneurysmal subarachnoid hemorrhage (aSAH) PSH, has been relatively understudied and is often misdiagnosed as an aSAH-related hyperadrenergic crisis. This study aims to clarify the feature of stroke-related PSH.

METHODS

This study discusses the case of a patient with post-aSAH PSH and identifies 19 articles (25 cases) on stroke-related PSH by searching the PubMed database from 1980 to 2021.

RESULTS

In the total cohort, 15 (60.0%) patients were male and the average age was 40.1 ± 16.6 years. The primary diagnoses included intracranial hemorrhage (13 cases, 52.0%), cerebral infarction (7 cases, 28.0%), subarachnoid hemorrhage (4 cases, 16.0%), and intraventricular hemorrhage (1 case, 4.0%). The sites of stroke damage were predominantly the cerebral lobe (10 cases, 40.0%), basal ganglia (8 cases, 32.0%), and the pons (4 cases, 16.0%). The median time of PSH onset after admission was 5 (1-180) days. Most cases employed combination therapy with sedation drugs, beta-blockers, gabapentin, and clonidine. On the Glasgow Outcome Scale, outcomes included death (4 cases, 21.1%), vegetative state (2 cases, 10.5%), severe disability (7 cases, 36.8%), and in only one case (5.3%) was a good recovery noted.

CONCLUSIONS

The clinical features and treatment of post-aSAH PSH differed from those of aSAH-related hyperadrenergic crises. Early diagnosis and treatment can prevent severe complications. PSH should be acknowledged as a potential complication of aSAH. Differential diagnosis can aid in developing individualized treatment plans and improving patient prognosis.

Paroxysmal Sympathetic Hyperactivity After Acquired Brain Injury: An Integrative Literature Review

BACKGROUND

Paroxysmal sympathetic hyperactivity may occur in patients with acute brain injury and is associated with physical disability, poor clinical outcomes, prolonged hospitalization, and higher health care costs.

OBJECTIVE

To comprehensively review current literature and provide information about paroxysmal sympathetic hyperactivity for nurses.

METHODS

An integrative literature review was conducted according to Whittemore and Knafl's method. The search was conducted from October 2020 through January 2021. The main targets of the literature search were definition, incidence rate, causes, clinical characteristics, pathophysiology, diagnosis, and treatment of paroxysmal sympathetic hyperactivity in pediatric and adult patients. The results were reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

The most characteristic clinical features of paroxysmal sympathetic hyperactivity are hypertension, tachycardia, tachypnea, hyperthermia, diaphoresis, and abnormal motor posturing. Reported incidence rates of paroxysmal sympathetic hyperactivity in patients with brain injury range from 8% to 33%. Various diagnostic criteria have been proposed; most are based on clinical symptoms. Ruling out other causes of the signs and symptoms of paroxysmal sympathetic hyperactivity is important because the signs and symptoms are nonspecific. The major goals of paroxysmal sympathetic hyperactivity management are avoidance of stimuli that may trigger a paroxysmal episode, inhibition of sympathetic overactivity, and prevention of damage to other organs.

CONCLUSIONS

Critical care nurses should be aware of the signs and symptoms of paroxysmal sympathetic hyperactivity in patients with acute brain injury. Early identification is important to ensure timely treatment for patients with paroxysmal sympathetic hyperactivity.