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• W4387248575 abstract "SESSION TITLE: Critical Care Case Report Posters 36 SESSION TYPE: Case Report Posters PRESENTED ON: 10/10/2023 09:40 am - 10:25 am INTRODUCTION: Episodes of paroxysmal sympathetic hyperactivity, which involves tachycardia, elevated blood pressure, fever spikes and muscular rigidity, are not uncommon in patients with severe traumatic brain injury. However, these episodes are also seen in patients with tumors, neuroinfections, hydrocephalus, hemorrhage and anoxic brain injury. We present a case report of a patient who had intracranial hemorrhage complicated by hydrocephalus and developed paroxysmal sympathetic storm. CASE PRESENTATION: 44 years old man with past medical history of hypertension, obstructive sleep apnea and history of DVT presented to the hospital with a large subarachnoid hemorrhage from a ruptured anterior communicating artery aneurysm. He underwent coiling of the aneurysm and later developed communicating hydrocephalus for which External ventricular drain (EVD) was temporarily placed. Patient's stay in the hospital was complicated, he was intubated, transferred to ICU and sent to Long-term acute care hospital (LTAC) to continue his care. Though still bedridden and weak, patient continued to improve neurologically. However, two months into recovery his condition started worsening, he became more somnolent, less responsive, started grimacing in pain, developed fever spikes and was noted to have increased bilateral upper and lower extremity rigidity. Infection, Seizures, and neuroleptic malignant syndrome were suspected as part of initial differential diagnosis, all were ruled out with appropriate workup, treatment and diagnostic modalities. After excluding other most common reasons for patient's symptoms, diagnosis of sympathetic storm was suspected. External cooling with cooling blankets for hyperthermia, Bromocriptine (dopamine D2 receptor agonist) and morphine to dampen the sympathetic outflow, Propranolol (nonselective B-adrenergic blockade) and clonidine were added for tachycardia and hypertension. Patient's symptoms gradually began to improve. DISCUSSION: The so-called sympathetic storm, also known as diencephalic seizures, was first described by Penfield in 1929 [1]. They are characterized by marked swings in body temperature, blood pressure, heart rate, and are associated with profuse sweating, retention of urine, and muscle rigidity. However, later reports of diencephalic seizures did not correlate with the electroencephalogram seizure activity nor were they responsive to anticonvulsants. Thus, PAID seems more appropriate. It usually occurs during the recovery period but can begin as early as the second day after brain injury. It can continue for weeks to months, and in some cases even for up to a year [2].Seen in up to one third of patients with severe brain injury, and young patients appear to be more prone to developing this complication [3]. The criteria for diagnosis includes severe brain injury, temperature of at least 38.5°, pulse of at least 130 bpm, respiratory rate at of least 30 breaths for minute, agitation, diaphoresis, dystonia (i.e. muscle rigidity or decerebrate posturing) [3]. CONCLUSIONS: PAID is a strict clinical diagnosis and needs to be differentiated from other conditions with similar symptoms. Diagnosis can be challenging, especially during early stage of acute brain injury because patients are heavily sedated for ventilation and/or pain relieve. Awareness of PAID may help to minimize the unnecessary expensive testing and start appropriate treatment early in the course, as it could possibly decrease morbidity in patients with brain injury. REFERENCE #1: Paroxysmal autonomic instability with dystonia. Sheila Srinivasan, MBBS, MRCP et al. Clin Auton Res. 2007;17:378-381. https://doi.org/10.1007/s10286-007-0428-x REFERENCE #2: Paroxysmal Autonomic Instability with Dystonia After Brain Injury. James A. Blackman, MD, MPH; Peter D. Patrick, PhD; Marcia L. Buck, PharmD; et al. Arch Neurol. 2004;61(3):321-328. https://doi.org/10.1001/archneur.61.3.321 REFERENCE #3: Treatment of Paroxysmal Sympathetic Hyperactivity. Alejandro A. Rabinstein, MD, Eduardo E. Benarroch, MD. Current Treatment Options in Neurology. 2008;10:151-157. https://doi.org/10.1007/s11940-008-0016-y DISCLOSURES: No relevant relationships by Yashveer Lahori No relevant relationships by Anna Lahori No relevant relationships by Kirtenkumar Patel No relevant relationships by Zeeshan Tirmizi" @default.
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• W4387248575 date "2023-10-01" @default.
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• W4387248575 title "PAROXYSMAL AUTONOMIC INSTABILITY WITH DYSTONIA (PAID) IN A PATIENT WITH INTRACRANIAL HEMORRHAGE" @default.
• W4387248575 doi "https://doi.org/10.1016/j.chest.2023.07.1887" @default.
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