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

Abstract

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 underrecognized 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.

Identification and Management of Paroxysmal Sympathetic Hyperactivity After Traumatic Brain Injury

“…Previous and recent cases provide evidence that PSH-AM can not only serve as reliable diagnostic criteria, but also stratify the severity of PSH (10,57). The tool is able to dynamically monitor the evolution of individual PSH patients' clinical status, and is also valuable in diagnosing PSH in different types of brain trauma [e.g., diffuse axonal injury; (57,58)]. Given that further assessment and inspection due to persistent symptoms is necessary in the treatment of patients with TBI, PSH-AM can help to avoid misdiagnosis, enhance diagnostic efficiency, save time, and reduce economic costs.…”

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

“…Diagnosis of PSH is made by combination of "CFS" score and "DLT" score, named as PSH-AM (assessment measure) score. [6][7][8][9][10] Our patient presented with cyclic sympathetic storm with PSH-AM score of 21 after acquired brain injury, suggested "probable" diagnosis of PSH. Differential diagnosis for a patient presenting with altered mental status, muscle rigidity, hyperpyrexia and autonomic instability includes malignant hyperthermia, neuroleptic malignant syndrome, narcotic withdrawal syndrome, thyroid storm and encephalitis.…”

“…PSH contributes to troublesome clinical effects including worst clinical outcome, physical disability, prolonged hospital stay and high cost for health care. [6][7][8][9][10] Here, we discuss a case of PSH secondary to intracranial hemorrhage after warfarin toxicity.…”

Successful Management of Paroxysmal Sympathetic Hyperactivity in Anti-N-Methyl-D-Aspartate Receptor Encephalitis

“…The PSH-AM score is calculated by combining the clinical feature scale (CFS) score and diagnosis likelihood tool (DLT) score, which gives an estimate of the probability of a diagnosis of PSH [3]. In a case series [1], among 394 survivors of 521 patients admitted with acquired brain injury, 6 patients (1.5%) were diagnosed as PSH by using PSH-AM. This study showed that PSH-AM provides a more objective measure to increase the clinical certainty of diagnosing PSH.…”

“…Paroxysmal sympathetic hyperactivity (PSH) is a distinct syndrome which is characterized by paroxysmal transient hyperthermia, tachycardia, hypertension, tachypnea, excessive diaphoresis and specific posturing [1]. PSH is commonly described in traumatic brain injury (TBI) but not commonly recognized in anti-NMDAR encephalitis and the reports have been sparse.…”