eMedicine Specialties > Physical Medicine and Rehabilitation > Traumatic Brain Injury

Post Head Injury Autonomic Complications: Differential Diagnoses & Workup

Author: Stephen Kishner, MD, Residency Program Director, Professor of Clinical Medicine, Department of Medicine, Section of Physical Medicine and Rehabilitation, Louisiana State University School of Medicine
Coauthor(s): Joseph Augustin, MD, Resident, Section of Physical Medicine and Rehabilitation, Louisiana State University School of Medicine; Scott Strum, MD, Director of Traumatic Brain Injury Service, Assistant Professor, Department of Physical Medicine and Rehabilitation, Loma Linda University Medical Center
Contributor Information and Disclosures

Updated: Jul 24, 2008

Differential Diagnoses

Delirium Tremens
Dystonias
Meningitis
Neuroleptic Malignant Syndrome
Sepsis
Thyroid Storm

Other Problems to Be Considered

Lethal catatonia
Malignant hyperthermia
Infection
Serotonin syndrome

Workup

Laboratory Studies

  • Complete blood count (CBC) - To reveal potential infection (Elevated white blood cell and/or platelet counts may signal infection.)
  • Blood cultures - To rule out sepsis
  • Sputum cultures - To rule out pneumonia
  • Urine cultures and urinalysis - To rule out urinary tract infection
  • Sputum Gram stain - To rule out infection
  • Plasma catecholamine levels - May be of interest acutely but are not required for the diagnosis
  • Thyroid panel - To rule out thyroid storm
  • Random chemistry panel - To rule out neuroleptic malignant syndrome
  • Plasma creatine kinase and troponin levels - To rule out acute MI, neuroleptic malignant syndrome, and serotonin syndrome

Imaging Studies

  • Chest radiograph - To rule out pneumonia and atelectasis
  • Duplex ultrasonogram - To rule out DVT
  • Electrocardiogram (ECG) - To rule out MI
  • Head computed tomography (CT) or magnetic resonance imaging (MRI) scan - To rule out abscess, encephalitis, or hydrocephalus

Procedures

  • Lumbar puncture - To rule out meningitis

More on Post Head Injury Autonomic Complications

Overview: Post Head Injury Autonomic Complications
Differential Diagnoses & Workup: Post Head Injury Autonomic Complications
Treatment & Medication: Post Head Injury Autonomic Complications
Follow-up: Post Head Injury Autonomic Complications
References
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References

  1. Baguley IJ, Heriseanu RE, Cameron ID, et al. A critical review of the pathophysiology of dysautonomia following traumatic brain injury. Neurocrit Care. 2008;8(2):293-300. [Medline].

  2. Baguley IJ. The excitatory:inhibitory ratio model (EIR model): An integrative explanation of acute autonomic overactivity syndromes. Med Hypotheses. 2008;70(1):26-35. [Medline].

  3. Srinivasan S, Lim CC, Thirugnanam U. Paroxysmal autonomic instability with dystonia. Clin Auton Res. Dec 2007;17(6):378-81. [Medline].

  4. Blackman JA, Patrick PD, Buck ML, et al. Paroxysmal autonomic instability with dystonia after brain injury. Arch Neurol. Mar 2004;61(3):321-8. [Medline]. [Full Text].

  5. Rabinstein AA. Paroxysmal sympathetic hyperactivity in the neurological intensive care unit. Neurol Res. Oct 2007;29(7):680-2. [Medline].

  6. Baguley IJ, Nicholls JL, Felmingham KL. Dysautonomia after traumatic brain injury: a forgotten syndrome?. J Neurol Neurosurg Psychiatry. Jul 1999;67(1):39-43. [Medline]. [Full Text].

  7. De Tanti A, Gasperini G, Rossini M. Paroxysmal episodic hypothalamic instability with hypothermia after traumatic brain injury. Brain Inj. Dec 20 2005;19(14):1277-83. [Medline].

  8. Baguley IJ, Cameron ID, Green AM, et al. Pharmacological management of dysautonomia following traumatic brain injury. Brain Inj. May 2004;18(5):409-17. [Medline].

  9. Becker R, Benes L, Sure U, et al. Intrathecal baclofen alleviates autonomic dysfunction in severe brain injury. J Clin Neurosci. Jul 2000;7(4):316-9. [Medline].

  10. Baguley IJ, Heriseanu RE, Gurka JA, et al. Gabapentin in the management of dysautonomia following severe traumatic brain injury: a case series. J Neurol Neurosurg Psychiatry. May 2007;78(5):539-41. [Medline].

  11. Chiolero RL, Breitenstein E, Thorin D. Effects of propranolol on resting metabolic rate after severe head injury. Crit Care Med. Apr 1989;17(4):328-34. [Medline].

  12. Rossitch E, Bullard DE. The autonomic dysfunction syndrome: aetiology and treatment. Br J Neurosurg. 1988;2(4):471-8. [Medline].

  13. Russo RN, O'Flaherty S. Bromocriptine for the management of autonomic dysfunction after severe traumatic brain injury. J Paediatr Child Health. Jun 2000;36(3):283-5. [Medline].

  14. Baguley IJ, Slewa-Younan S, Heriseanu RE, et al. The incidence of dysautonomia and its relationship with autonomic arousal following traumatic brain injury. Brain Inj. Oct 2007;21(11):1175-81. [Medline].

  15. Baguley IJ. Nomenclature of "paroxysmal sympathetic storms". Mayo Clin Proc. Jan 1999;74(1):105. [Medline].

  16. Boeve BF, Wijdicks EF, Benarroch EE. Paroxysmal sympathetic storms ("diencephalic seizures") after severe diffuse axonal head injury. Mayo Clin Proc. Feb 1998;73(2):148-52. [Medline].

  17. Cheshire WP, Freeman R. Disorders of sweating. Semin Neurol. Dec 2003;23(4):399-406. [Medline].

  18. Clifton GL, Robertson CS, Kyper K. Cardiovascular response to severe head injury. J Neurosurg. Sep 1983;59(3):447-54. [Medline].

  19. Clifton GL, Ziegler MG, Grossman RG. Circulating catecholamines and sympathetic activity after head injury. Neurosurgery. Jan 1981;8(1):10-4. [Medline].

  20. Fernández-Ortega JF, Prieto-Palomino MA, Muñoz-López A, et al. [Dysautonomic seizures in patients admitted to an intensive care unit following severe traumatic brain injury]. Rev Neurol. Oct 16-31 2004;39(8):715-8. [Medline].

  21. Hamill RW, Woolf PD, McDonald JV. Catecholamines predict outcome in traumatic brain injury. Ann Neurol. May 1987;21(5):438-43. [Medline].

  22. Horn LJ, Sherer M. Rehabilitation of traumatic brain injury. In: Grabois M, Garrison SJ, Hart KA, et al, eds. Physical Medicine and Rehabilitation: The Complete Approach. Malden, Mass: Blackwell Science; 2000:1290-1.

  23. Meythaler JM, Stinson AM. Fever of central origin in traumatic brain injury controlled with propranolol. Arch Phys Med Rehabil. Jul 1994;75(7):816-8. [Medline].

  24. Ropper AH. Acute autonomic emergencies and autonomic storm. In: Low PA, ed. Clinical Autonomic Disorders. Boston, Mass: Little, Brown; 1993:747-56.

  25. Sandel ME, Abrams PL, Horn LJ. Hypertension after brain injury: case report. Arch Phys Med Rehabil. Jul 1986;67(7):469-72. [Medline].

  26. Scott JS, Ockey RR, Holmes GE. Autonomic dysfunction associated with locked-in syndrome in a child. Am J Phys Med Rehabil. May-Jun 1997;76(3):200-3. [Medline].

  27. Sherman MA, Shutov AA. [Clinical course of autonomic nervous system disorders in veterans with consequences of combat mild brain injury]. Zh Nevrol Psikhiatr Im S S Korsakova. 2003;103(1):17-20. [Medline].

  28. Shiozaki T, Taneda M, Kishikawa M, et al. Transient and repetitive rises in blood pressure synchronized with plasma catecholamine increases after head injury. Report of two cases. J Neurosurg. Mar 1993;78(3):501-4. [Medline].

  29. Thorley RR, Wertsch JJ, Klingbeil GE. Acute hypothalamic instability in traumatic brain injury: a case report. Arch Phys Med Rehabil. Feb 2001;82(2):246-9. [Medline].

  30. Whyte J, Filion DT, Rose TR. Defective thermoregulation after traumatic brain injury. A single subject evaluation. Am J Phys Med Rehabil. Oct 1993;72(5):281-5. [Medline].

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Further Reading

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Keywords

autonomic dysfunction syndrome, ADS, dysautonomia, paroxysmal sympathetic storm, autonomic storm, neurostorming, diencephalic seizure, acute midbrain syndrome, brainstem attack, hypothalamic-midbrain dysregulation syndrome, hyperpyrexia associated with muscle contraction, paroxysmal autonomic instability with dystonia, PAID, traumatic brain injury, TBI, hydrocephalus, brain tumor, subarachnoid hemorrhage, intracerebral hemorrhage

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Contributor Information and Disclosures

Author

Stephen Kishner, MD, Residency Program Director, Professor of Clinical Medicine, Department of Medicine, Section of Physical Medicine and Rehabilitation, Louisiana State University School of Medicine
Stephen Kishner, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and American Association of Neuromuscular and Electrodiagnostic Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Joseph Augustin, MD, Resident, Section of Physical Medicine and Rehabilitation, Louisiana State University School of Medicine
Disclosure: Nothing to disclose.

Scott Strum, MD, Director of Traumatic Brain Injury Service, Assistant Professor, Department of Physical Medicine and Rehabilitation, Loma Linda University Medical Center
Scott Strum, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

Medical Editor

Teresa L Massagli, MD, Residency Director, Professor, Department of Rehabilitation Medicine and Pediatrics, University of Washington School of Medicine
Teresa L Massagli, MD is a member of the following medical societies: American Academy of Pediatrics, American Academy of Physical Medicine and Rehabilitation, and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Kat Kolaski, MD, Assistant Professor, Departments of Orthopedic Surgery and Pediatrics, Wake Forest University School of Medicine
Kat Kolaski, MD is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine and American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Lourdes Regional Rehabilitation Center, Our Lady of Lourdes Medical Center
Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Alegent Health Care, Immanuel Rehabilitation Center
Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

 
 
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