Neuroleptic malignant syndrome and closed head injury: A case report and review

Neuroleptic malignant syndrome (NMS) is a rare, but potentially lethal neurological emergency. Fifty percent of traumatic brain injury (TBI) patients will have emotional disorders and post-traumatic agitations. Haloperidol is a neuroleptic antipsychotic medication commonly used in the traumatic brain injury patients due to its advantage of no effect on respiration and conscious level. But it is one of the common medications causing NMS. A 19-year-old male driver involved in the road traffic accident had an acute subdural hematoma, which was immediately evacuated. Postoperatively, he was awake. He was weaned from ventilator and extubated. He received 20 mg of intravenous haloperidol in divided doses with in 24 hours to control his agitation. Next day, he became drowsy, spastic, febrile, and tachycardic with labile blood pressure. He was diagnosed to have NMS, needed intubation, aggressive hydration and pharmacological treatment with dentrolene sodium and bromocriptin. He was weaned from ventilator and extubated on day 17. He was transferred to the ward and then discharged to be followed in out-patient clinic. NMS in head injury patient is rare and difficult to diagnose. Diagnosis of NMS should be suspected if two of the four cardinal signs and symptoms are developed following the use of neuroleptic or dopamine agonist medication withdrawal.