Skip to main content
SpringerLink
Log in

Paroxysmal Sympathetic Hyperactivity Following Acute Acquired Brain Injury

  • Chapter
  • First Online:
Challenging Topics in Neuroanesthesia and Neurocritical Care

Abstract

Paroxysmal sympathetic hyperactivity develops following acute brain insult from diverse pathological conditions. The episodic sympathetic hyperactivity results in hypertension, tachycardia, tachypnea, rise in body temperature, excessive diaphoresis, and dystonia. Its prevalence is more common in males, and is generally identified during patient’s liberation from mechanical ventilator and withdrawal of sedation/muscle relaxant. The episode may follow various stimuli, including nonnoxious stimuli such as touch or even sound. Its onset is usually after a week of acute brain insult and may last up to 1 year. There are no specific signs on magnetic resonance imaging (MRI) of brain but it is suspected that patients of diffuse axonal injury on MRI are more prone to get this syndrome. Its definite etiology remains elusive. The most popular theory of excitatory–inhibitory ratio model tends to explain the sympathetic over-reactive nature of response of these patients even to nonallodynic stimuli. Its management is symptomatic and supportive; the mainstay of management relies on morphine and propranolol. Typically, beta-blockers are used to minimize the frequency of the spells, whereas morphine is administered to abort the episodes. Many second-line agents have also been used in refractory cases with variable success rate. Patients who suffer from this entity have higher incidence of various systemic complications. Early recognition is highly essential to avoid unnecessary, costly investigations and for proper management.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 79.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 129.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 139.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Baguley IJ, Slewa-Younan S, Heriseanu RE, Nott MT, Mudaliar Y, Nayyar V. The incidence of dysautonomia and its relationship with autonomic arousal following traumatic brain injury. Brain Inj. 2007;21(11):1175–81.

    Article  PubMed  Google Scholar 

  2. Jennett B, Teasdale G, Galbraith S, Pickard J, Grant H, Braakman R, et al. Severe head injuries in three countries. J Neurol Neurosurg Psychiatry. 1977;40(3):291–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Choi HA, Jeon SB, Samuel S, Allison T, Lee K. Paroxysmal sympathetic hyperactivity after acute brain injury. Curr Neurol Neurosci Rep. 2013;13(8):370.

    Article  PubMed  Google Scholar 

  4. Perkes I, Baguley IJ, Nott MT, Menon DK. A review of paroxysmal sympathetic hyperactivity after acquired brain injury. Ann Neurol. 2010;68(2):126–35.

    Article  PubMed  Google Scholar 

  5. Baguley IJ, Perkes IE, Fernandez-Ortega JF, Rabinstein AA, Dolce G, Hendricks HT. Paroxysmal sympathetic hyperactivity after acquired brain injury: Consensus on conceptual definition, nomenclature, and diagnostic criteria. J Neurotrauma. 2014;31:1515–20.

    Article  PubMed  Google Scholar 

  6. Hinson HE, Sheth KN. Manifestations of the hyperadrenergic state after acute brain injury. Curr Opin Crit Care. 2012;18(2):139–45.

    Article  PubMed  Google Scholar 

  7. Lv LQ, Hou LJ, Yu M, Qi XO, Chen JX, Hu GH, et al. Risk factors related to dysautonomia after severe traumatic brain injury. J Trauma. 2011;71(3):538–42.

    PubMed  Google Scholar 

  8. Baguley IJ, Nicholls JL, Felmingham KL, Crooks J, Gurka JA, Wade LD. Dysautonomia after traumatic brain injury: a forgotten syndrome? J Neurol Neurosurg Psychiatry. 1999;67(1):39–43.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Baguley IJ, Heriseanu RE, Gurka JA, Nordenbo A, Cameron ID. Gabapentin in the management of dysautonomia following severe traumatic brain injury: a case series. J Neurol Neurosurg Psychiatry. 2007;78(5):539–41.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Penfield W. Diencephalic autonomic epilepsy. Arch Neurol Psychiatry. 1929;22:358–74.

    Article  Google Scholar 

  11. Rabinstein AA. Paroxysmal sympathetic hyperactivity in the neurological intensive care unit. Neurol Res. 2007;29(7):680–2.

    Article  PubMed  Google Scholar 

  12. Fernandez-Ortega JF, Prieto-Palomino MA, Garcia-Caballero M, Galeas-Lopez JL, Quesada-Garcia G, Baguley IJ. Paroxysmal sympathetic hyperactivity after traumatic brain injury: clinical and prognostic implications. J Neurotrauma. 2012;29(7):1364–70.

    Article  PubMed  Google Scholar 

  13. Perkes IE, Menon DK, Nott MT, Baguley IJ. Paroxysmal sympathetic hyperactivity after acquired brain injury: a review of diagnostic criteria. Brain Inj. 2011;25(10):925–32.

    Article  PubMed  Google Scholar 

  14. Rabinstein AA, Benarroch EE. Treatment of paroxysmal sympathetic hyperactivity. Curr Treat Options Neurol. 2008;10(2):151–7.

    Article  PubMed  Google Scholar 

  15. Dolce G, Quintieri M, Leto E, Milano M, Pileggi A, Lagani V, et al. Dysautonomia and clinical outcome in vegetative State. J Neurotrauma. 2008;50:502–4.

    Google Scholar 

  16. Fearnside MR, Cook RJ, McDougall P, McNeil RJ. The Westmead head injury project outcome in severe head injury. A comparative analysis of pre-hospital, clinical and CT variables. Br J Neurosurg. 1993;7(3):267–79.

    Article  CAS  PubMed  Google Scholar 

  17. Fernandez-Ortega JF, Prieto-Palomino MA, Munoz-Lopez A. Lebron- Gallardo M, Cabrera-Ortiz H, Quesada-Garcia G. Prognostic influence and computed tomography findings in dysautonomic crises after traumatic brain injury. J Trauma. 2006;61(5):1129–33.

    Article  PubMed  Google Scholar 

  18. Hendricks HT, Geurts AC, van Ginnken BC, Heeren AJ, Vos PE. Brain Injury severity and autonomic dysregulation accurately predict heterotopic ossification in patients with traumatic brain injury. Clin Rehabil. 2007;21(6):545–53.

    Article  PubMed  Google Scholar 

  19. Moeller RF, Carpenter JL, Dean N, Wells EM. Paroxysmal Sympathetic hyperactivity in critically ill Children with encephalitis and meningoencephalitis. Neurocrit Care. 2015;23(3):380–5.

    Article  Google Scholar 

  20. Dalmau J, Tuzun E, Wu HY, Masjuan J, Rossi JE, Voloschin A, et al. Paraneoplastic anti-N-methyl- D-aspartate receptor encephalitis associated with ovarian teratoma. Ann Neurol. 2007;61(1):25–36.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Nazif TM, Vázquez J, Honig LS, Dizon JM. Anti-N-methyl-D-aspartate receptor encephalitis: an emerging cause of centrally mediated sinus node dysfunction. Europace. 2012;14(8):1188–94.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Gao B, Jeffrey A, Holly P, Hinson E. Paroxysmal sympathetic hyperactivity in hemispheric intraparenchymal haemorrhage. Annals of Clinical and Translational Neurology. 2014;1(3):215–9.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Liu Y, Jolly S, Pokala K. Prolonged Paroxysmal Sympathetic Storming Associated withSpontaneous Subarachnoid Hemorrhage. Case Reports in Medicine. 2013;1-4

    Google Scholar 

  24. Ramdhani NA, Sikma MA, Witkamp TD, Slooter AJC, de Lange DW. Paroxysmal autonomic instability with dystonia in a patient with tuberculous meningitis: a case report. J Medical Case Reports. 2010;4:304.

    Article  Google Scholar 

  25. Baguley IJ, Heriseanu RE, Felmingham KL, Cameron ID. Dysautonomia and heart rate variability following severe traumatic brain injury. Brain Inj. 2006;20(4):437–44.

    Article  PubMed  Google Scholar 

  26. Boeve BF, Wijdicks EF, Benarroch EE, Schmidt KD. Parxysmal sympathetic storms (diencephalic seizure) after severe diffuse axonal head injury. Mayo Clin Proc. 1998;73(2):148–52.

    Article  CAS  PubMed  Google Scholar 

  27. Bullard DE. Diencephalic seizures: responsiveness to bromocriptine and morphine. Ann Neurol. 1987;21(6):609–11.

    Article  CAS  PubMed  Google Scholar 

  28. Dalmau J, Gleichman AJ, Hughes EG, Rossi JE, Peng X, Lai M, et al. Anti-NMDA-receptor encephalitis: case series and analysis of the effects of antibodies. Lancet Neurol. 2008;7(12):1091–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Pranzatelli MR, Pavlakis SG, Gould RJ, De Vivo DC. Hypothalamic-midbrain dysregulation syndrome: hypertension, hyperthermia, hyperventilation, and decerebration. J Child Neurol. 1991;6(2):115–22.

    Article  CAS  PubMed  Google Scholar 

  30. Thorley RR, Wertsch JJ, Klingbeil GE. Acute hypothalamic instability in traumatic brain injury: a case report. Arch Phys Med Rehabil. 2001;82(2):246–9.

    Article  CAS  PubMed  Google Scholar 

  31. Carmel PW. Vegetative dysfunctions of the hypothalamus. Acta Neurochir (Wien). 1985;75(1-4):113–21.

    Article  CAS  Google Scholar 

  32. Doshi R, Neil-Dwyer G. Hypothalamic and myocardial lesions after subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry. 1977;40(8):821–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  33. Reynolds RW. Pulmonary Edema as a consequence of hypothalamic lesions in rats. Science. 1963;141(3584):930–2.

    Article  CAS  PubMed  Google Scholar 

  34. Baguley IJ. The excitatory:inhibitory ratio model (EIR model): An integrative explanation of acute autonomic overactivity syndromes. Med Hypotheses. 2008;70(1):26–35.

    Article  PubMed  Google Scholar 

  35. Baguley IJ, Heriseanu RE, Nott MT, Chapman J, Sandanam J. Dysautonomia after severe traumatic brain injury: evidence of persisting overresponsiveness to afferent stimuli'. Am J Phys Med Rehabil. 2009;88(8):615–22.

    Article  PubMed  Google Scholar 

  36. Baguley IJ, Nott MT, Slewa-Younan S, Heriseanu RE, Perkes IE. Diagnosing dysautonomia after acute traumatic brain injury: evidence for overresponsiveness to afferent stimuli. Arch Phys Med Rehabil. 2009;90(4):580–6.

    Article  PubMed  Google Scholar 

  37. Baguley IJ, Heriseanu RE, Cameron ID, Nott MT. Slewa-Younan S.A critical review of the pathophysiology of dysautonomia following traumatic brain injury. Neurocrit Care. 2008;8(2):293–300.

    Article  PubMed  Google Scholar 

  38. Lv LQ, Hou LJ, Yu MK, Qi XQ, Chen HR, Chen JX, et al. 'Prognostic influence and magnetic resonance imaging findings in paroxysmal sympathetic hyperactivity after severe traumatic brain injury. J Neurotrauma. 2010;27(11):1945–50.

    Article  PubMed  Google Scholar 

  39. Cuny E, Richer E, Castel JP. Dysautonomia syndrome in the acute recovery phase after traiumatic brain injury: relief with intrathecal baclofen therapy. Brain Inj. 2001;15(10):917–25.

    Article  CAS  PubMed  Google Scholar 

  40. Krach LE, Kriel RL, Morris WF, Warhol BL, Luxenberg MG. Central autonomic dysfunction following acquired brain injury in children. Neuroreahabil Neural Repair. 1997;11:41–5.

    Article  Google Scholar 

  41. Becker R, Benes L, Sure U, Hellwig D, Bertalaeffy H. Intrathecal baclofen alleviates autonomic dysfunction in severe brain injury. J ClinNeurosci. 2000;7(4):316–9.

    CAS  Google Scholar 

  42. Ko S-B, Kim CK, Lee S-H, et al. Morphine-sensitive paroxysmal sympathetic storm in pontine intracerebral hemorrhage. Neurologist. 2010;16(6):384–5.

    Article  PubMed  Google Scholar 

  43. Rossitch Jr E, Bullard DE. The autonomic dysfunction syndrome: aetiology and treatment. Br J Neurosurg. 1988;2(4):471–8.

    Article  PubMed  Google Scholar 

  44. Siu G, Marino M, Desai A, Nissley F. Sympathetic storming in a patient with intracranial basal ganglia hemorrhage. Am J Phys Med Rehabil. 2011;90(3):243–6.

    Article  PubMed  Google Scholar 

  45. Tong C, Konig MW, Roberts PR, Tatter SB, Li XH. Autonomic dysfunction secondary to intracerebral hemorrhage. Anesth Analg. 2000;91(6):1450–1.

    Article  CAS  PubMed  Google Scholar 

  46. Baguley IJ, Cameron ID, Green AM, Slewa-Younan S, Marosszeky JE, Gurka JA. Pharmacological management of Dysautonomia following traumatic brain injury. Brain Inj. 2004;18(5):409–17.

    Article  PubMed  Google Scholar 

  47. Hendricks HT, Heeren AH, Vos PE. Dysautonomia after severe traumatic brain injury. Eur J Neurol. 2010;17(9):1172–7.

    Article  CAS  PubMed  Google Scholar 

  48. Zhang J, Mitsis EM, Chu K, Newmark RE, Hazlett EA, Buchsbaum MS. Statistical parametric mapping and cluster counting analysis of [18F] FDG-PET imaging in traumatic brain injury. J Neurotrauma. 2010;27(1):35–49.

    Article  PubMed  Google Scholar 

  49. Blackman JA, Patrick PD, Buck ML, Rust Jr RS. Paroxysmal autonomic instability with dystonia after brain injury. Arch Neurol. 2004;61(3):321–8.

    Article  PubMed  Google Scholar 

  50. Goddeau Jr RP, Silverman SB, Sims JR. Dexmedetomidine for the treatment of paroxysmal autonomic instability with dystonia. Neurocrit Care. 2007;7(3):217–20.

    Article  CAS  PubMed  Google Scholar 

  51. Rabinstein AA. Paroxysmal autonomic instability after brain injury. Arch Neurol. 2004;61(10):1625.

    Article  PubMed  Google Scholar 

  52. Kelly AB, Zimmerman RD, Snow RB, Gandy SE, Heier LA, Deck MD. Head trauma: comparison of MR and CT--experience in 100 patients. AJNR. 1988;9(4):699–708.

    CAS  PubMed  Google Scholar 

  53. Diesing TS, Wijdicks EF. Arc de cercle and dysautonomia from anoxic injury. Mov Disord. 2006;21(6):868–9.

    Article  PubMed  Google Scholar 

  54. Huang P, Lin WC, Huang PK, Khor GT. Susceptibility weighted imaging in a patient with paroxysmal sympathetic storms. J Neurol. 2009;256(2):276–8.

    Article  PubMed  Google Scholar 

  55. Wang VY, Manley G. Recognition of paroxysmal autonomic instability with dystonia (PAID) in a patient with traumatic brain injury. J Trauma. 2008;64(2):500–2.

    Article  PubMed  Google Scholar 

  56. Clifton GL, Ziegler MG, Grossman RG. Circulating catecholamines and sympathetic activity after head injury. Neurosurgery. 1981;8(1):10–4.

    Article  CAS  PubMed  Google Scholar 

  57. Hughes JD, Rabinstein AA. Early diagnosis of paroxysmal sympathetic hyperactivity in the ICU. Neurocrit Care. 2014;20:454–9.

    Article  CAS  PubMed  Google Scholar 

  58. Srinivasan S, Lim CC, Thirugnanam U. Paroxysmal autonomic instability with dystonia. ClinAuton Res. 2007;17(6):378–81.

    Google Scholar 

  59. Oddo M, Carrera E, Claassen J, Mayer SA, Hirsch LJ. Continuous electroencephalography in the medical intensive care unit. Crit Care Med. 2009;37(6):2051–6.

    Article  PubMed  Google Scholar 

  60. Meyer KS. Understanding paroxysmal sympathetic hyperactivity after traumatic brain injury. SurgNeurol Int. 2014;5(Suppl 13):S490–2.

    Google Scholar 

  61. Mehta NM, Bechard LJ, Leavitt K, Duggan C. Severe weight loss and hypermetabolic paroxysmal dysautonomia following hypoxic ischemic brain injury: the role of indirect calorimetry in the intensive care unit. JPEN J Parenter Enteral Nutr. 2008;32(3):281–4.

    Article  PubMed  Google Scholar 

  62. Ott L, Young B, Phillips R, McClain C, Adams L, Dempsey R, Tibbs P, Ryo UY. Altered gastric emptying in the head-injured patient: relationship to feeding intolerance. J Neurosurg. 1991;74(5):738–42.

    Article  CAS  PubMed  Google Scholar 

  63. Scott JS, Ockey RR, Holmes GE, Varghese G. Autonomic dysfunction associated with locked-in syndrome in a child. Am J Phys Med Rehabil. 1997;76(3):200–3.

    Article  CAS  PubMed  Google Scholar 

  64. Ryan JB, Hicks M, Cropper JR, Garlick SR, Kesteven SH, Wilson MK, et al. Functional evidence of reversible ischemic injury immediately after the sympathetic storm associated withexperimental brain death. J Heart Lung Transplant. 2003;22(8):922–8.

    Article  PubMed  Google Scholar 

  65. Woiciechowsky C, Asadullah K, Nestler D, Eberhardt B, Platzer C, Schöning B, et al. Sympathetic activation triggers systemic interleukin-10 release in immunodepression induced by brain injury. Nat Med. 1998;4(7):808–13.

    Article  CAS  PubMed  Google Scholar 

  66. Baguley IJ. Autonomic complications following central nervous system injury’. Semin Neurol. 2008;28(5):716–25.

    Article  PubMed  Google Scholar 

  67. Do D, Sheen VL, Bromfield E. Treatment of paroxysmal sympathetic storm with labetalol. J Neurol Neurosurg Psychiatry. 2000;69(6):832–3.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  68. Chioléro RL, Breitenstein E, Thorin D, Christin L, de Tribolet N, Freeman J, et al. Effects of propranolol on resting metabolic rate after severe head injury. Crit Care Med. 1989;17(4):328–34.

    Article  PubMed  Google Scholar 

  69. Meythaler JM, Stinson 3rd AM. Fever of central origin in traumatic brain injury controlled with propranolol. Arch Phys Med Rehabil. 1994;75(7):816–8.

    CAS  PubMed  Google Scholar 

  70. Head GA, Chan CK, Burke SL. Relationship between imidazoline and alpha2-adrenoceptors involved in the sympatho-inhibitory actions of centrally acting antihypertensive agents. J Auton Nerv Syst. 1998;72(2-3):163–9.

    Article  CAS  PubMed  Google Scholar 

  71. Payen D, Quintin L, Plaisance P, Chiron B, Lhoste F. Head injury: clonidine decreases plasma catecholamines. Crit Care Med. 1990;18(4):392–5.

    Article  CAS  PubMed  Google Scholar 

  72. 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):965–8.

    Article  PubMed  PubMed Central  Google Scholar 

  73. Russo RN, O'Flaherty S. Bromocriptine for the management of autonomic dysfunction after severe traumatic brain injury. J Paediatr Child Health. 2000;36(3):283–5.

    Article  CAS  PubMed  Google Scholar 

  74. Cunningham JA, Jelic S. Baclofen withdrawal: a cause of prolonged fever in the intensive care unit. Anaesth Intensive Care. 2005;33(4):534–7.

    CAS  PubMed  Google Scholar 

  75. Lazar RM, Fitzsimmons BF, Marshall RS, Mohr JP, Berman MF. Midazolam challenge reinduces neurological deficits after transient ischemic attack. Stroke. 2003;34(3):794–6.

    Article  CAS  PubMed  Google Scholar 

  76. Chan CH. Dantrolene sodium and hepatic injury. Neurology. 1990;40(9):1427–32.

    Article  CAS  PubMed  Google Scholar 

  77. Lv LQ, Hou LJ, Yu MK, Ding XH, Qi XQ, Lu YC. Hyperbaric oxygen therapy in the management of paroxysmal sympathetic hyperactivity after severe traumatic brain injury: a report of 6 cases. Arch Phys Med Rehabil. 2011;92(9):1515–8.

    Article  PubMed  Google Scholar 

  78. Greer DM, Funk SE, Reaven NL, Ouzounelli M, Uman GC. Impact of fever on outcome in patients with stroke and neurologic injury: a comprehensive meta-analysis. Stroke. 2008;39(11):3029–35.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Neuroanaesthesiology and Critical Care, Neurosciences Centre, AIIMS, New Delhi, India

    Parmod Kumar Bithal

  2. Critical and Intensive Care, Department of Neuroanaesthesiology and Critical Care, Jai Prakash Narayan Apex Trauma Centre, AIIMS, New Delhi, India

    Keshav Goyal

Authors
  1. Parmod Kumar Bithal
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Keshav Goyal
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Parmod Kumar Bithal .

Editor information

Editors and Affiliations

  1. Anesthesiology and Intensive Care, Tehran University of Medical Sciences, Tehran, Iran

    Zahid Hussain Khan

Rights and permissions

Reprints and permissions

Copyright information

© 2017 Springer International Publishing Switzerland

About this chapter

Cite this chapter

Bithal, P.K., Goyal, K. (2017). Paroxysmal Sympathetic Hyperactivity Following Acute Acquired Brain Injury. In: Khan, Z. (eds) Challenging Topics in Neuroanesthesia and Neurocritical Care. Springer, Cham. https://doi.org/10.1007/978-3-319-41445-4_5

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-41445-4_5

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-41443-0

  • Online ISBN: 978-3-319-41445-4

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation