Refractory Paroxysmal Sympathetic Hyperactivity Following Traumatic Intracerebral Hemorrhage

Paroxysmal sympathetic hyperactivity (PSH) is a complex and underrecognized phenomenon involving increased sympathetic activity leading to tachycardia, tachypnea, and hypertension. The frequency of nonrecognition is due to a lack of diagnostic criteria. In addition, the lack of evidence-based treatments has further complicated approaches to management. This case describes a patient who presented with a new-onset seizure and intracerebral hemorrhage requiring burst suppression and decompressive craniotomy to attenuate intracranial hypertension (ICH). The patient continued to display paroxysmal dysautonomia requiring a multimodal regimen for control of episodes. He demonstrated neurological improvement and complete resolution of dysautonomic activity prior to being discharged to a rehabilitation facility. A delayed diagnosis, ICH, and refractory PSH status postdecompressive craniotomy presented unique challenges. Given that the number of episodes of paroxysmal "storms" directly correlates with morbidity and mortality, early detection is critical, and lack of recognition makes this a difficult disorder to diagnose and manage.