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

Abstract

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.

Neuroleptic Malignant Syndrome (NMS): A Rare Occurrence in Traumatic Brain Injury

“…To start with, it is given in the dose of 2.5 mg every six to eight hours orally or through nasogastric tube and can be titrated to a maximum dose of 40 mg per day. It should be continued for 10 days after the control of NMS and should be tapered before stopping [9,10].…”

“…Treatment of complications like renal failure might warrant renal replacement therapy. Electroconvulsive therapy (ECT) is required in NMS patients with catatonia, patients not responding to the medical therapy [9]. Literature about NMS associated with head injury patients is limited only to the case reports [11].…”

Neuroleptic Malignant Syndrome Status Post Anoxic Brain Injury: A Case Presentation of Heightened Susceptibility in the Brain Injury Population

“…Neuroleptic malignant syndrome (NMS) is a rare neurological condition characterized by muscle rigidity, autonomic instability, hyperthermia, and mental status changes most commonly secondary to treatment with dopamine-blocking antipsychotics, such as haloperidol [ 1 ]. NMS is typically also accompanied by characteristic laboratory abnormalities including elevated creatinine kinase (generally 4× the upper limit), low serum iron, leukocytosis, hyperkalemia, hypomagnesemia, hyponatremia or hypernatremia, metabolic acidosis, elevated blood urea nitrogen (BUN), and elevated lactate dehydrogenase (LDH) [ 2 ].…”