Autonomic dysreflexia and sudden death in people with traumatic spinal cord injury

Autonomic dysreflexia (AD) is an uncommon but potentially life-threatening clinical syndrome consisting of acute episodes of excessive, uncontrolled sympathetic output that may occur in quadriplegics and in paraplegics whose spinal cord lesions are above the level of T6. These uncontrolled bouts of sympathetic output can cause transient and pronounced elevations of blood pressure that on occasion can lead to serious sequela such as the precipitation of a hypertensive intracerebral hemorrhage. The episodes of AD are often triggered by some type of noxious stimulus such as a distended urinary bladder or a fecal impaction. We present the case of a 62-year-old man with a history of quadriplegia resulting from a diving accident 40 years ago that was complicated clinically by episodes of autonomic dysreflexia. While hospitalized, he experienced an episode of autonomic dysreflexia with severe hypertension, which was soon followed by neurologic deterioration and death. Antemortem imaging revealed a large hypertensive-type intracerebral hemorrhage originating in his right caudate nucleus. Although his death at first appeared to be a natural death due to a spontaneous hypertensive-type intracerebral hemorrhage, his clinically documented autonomic dysreflexia convincingly linked the remote spinal cord injury and the fatal intracerebral hemorrhage, engendering an accidental manner of death.