PSH

Q: All of the following may occur in Paroxysmal Sympathetic Hyperactivity (PSH) in patients with traumatic brain injury (TBI) EXCEPT? (select one)

A) tachycardia

B) hypertension

C) hyperthermia

D) dry skin

E) increased muscle tone

Answer: D

Due to its dramatic presentation, there have been many names for this phenomenon commonly observed in neuro-ICUs among TBI patients such as autonomic storms, sympathetic storms, hypothalamic dysregulation syndrome, dysautonomia, paroxysmal autonomic instability with dystonia, and diencephalic autonomic epilepsy (misnomer). But in 2014, it was decided in a consensus conference to name it as paroxysmal sympathetic hyperactivity (PSH).

It is a dysregulation syndrome of autonomic function and presents as recurrent episodes of excessive sympathetic activity, may induced by stimulation, and resolve spontaneously though medications may expedite its resolution. But, if left untreated, may continue to cause further brain injury. Most of the time it may not require any workup such as STAT CT.

It usually manifests as an episode of tachycardia, hypertension, tachypnea, hyperthermia, sweating, and/or increased muscle tone with possible dystonic posturing.

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References:

1. Meyfroidt G, Baguley IJ, Menon DK. Paroxysmal sympathetic hyperactivity: the storm after acute brain injury. Lancet Neurol 2017; 16:721.

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

3. Baguley IJ, Perkes IE, Fernandez-Ortega JF, et al. Paroxysmal sympathetic hyperactivity after acquired brain injury: consensus on conceptual definition, nomenclature, and diagnostic criteria. J Neurotrauma 2014; 31:1515.