Paroxysmal Autonomic Instability With Dystonia Managed Using Chemodenervation Including Alcohol Neurolysis and Botulinum Toxin Type A Injection: A Case Report

Abstract

Paroxysmal autonomic instability with dystonia (PAID) is a rare complication of brain injury. Symptoms of PAID include diaphoresis, hyperthermia, hypertension, tachycardia, and tachypnea accompanied by hypertonic movement. Herein, we present the case of a 44-year-old female patient, who was diagnosed with paraneoplastic limbic encephalopathy caused by thyroid papillary cancer. The patient exhibited all the symptoms of PAID. On the basis that the symptoms were unresponsive to antispastic medication and her liver function test was elevated, we performed alcohol neurolysis of the musculocutaneous nerve followed by botulinum toxin type A (BNT-A) injection into the biceps brachii and brachialis. Unstable vital signs and hypertonia were relieved after chemodenervation. Accordingly, alcohol neurolysis and BNT-A injection are proposed as a treatment option for intractable PAID.

Transdermal opioid patch in treatment of paroxysmal autonomic instability with dystonia with multiple cerebral insults

“…PAID mostly presents in patients with a single severe brain injury due to trauma or hypoxic events, occurring within 1 month after the underlying brain injury. [ 3 4 5 6 7 8 13 ] In our study, the patient's PAID occurred 3 months after the most recent ischemic stroke and coincided with severe injury of the brain astrocytoma and 2 occurrences of ischemic stroke. β-blockers (propranolol), bromocriptine, and clonazepam were administered to the patient, but the sympathetic storms continued.…”

“…[ 1 2 ] According to a previous study on this sympathetic hyperactivity, the incidence ranges from 8% to 33%, depending on underlying brain damage: traumatic brain injury (79.4%), hypoxic brain injury (9.7%), cerebrovascular disorder (5.4%), hydrocephalus (2.6%), tumor (0.6%), and infectious brain injury (0.3%). [ 1 2 3 4 5 6 7 8 ] The mechanism of PAID has been known to be disconnection of the cortical inhibitory center or imbalance between brain excitation and inhibition. [ 9 10 ] To prove these mechanisms and the underlying brain pathology, brain diffusion tensor imaging (DTI), which can show the disconnection of cortical, subcortical, and stem lesions, reportedly plays an effective role.…”

Paroxysmal Autonomic Instability with Dystonia after Severe Traumatic Brain Injury

“…PAID syndrome mainly manifests in the ICU but may persist for months during the patient's rehabilitation phase [1,2]. Apart from trauma and anoxic injury, PAID is associated with tuberculous meningitis [3], interpeduncular tuberculoma [4], pneumococcal meningoencephalitis [5], intracerebral hemorrhage [6] and paraneoplastic limbic encephalopathy [7]. Differential diagnosis of PAID include neuroleptic malignant syndrome, malignant hyperthermia, sepsis, thyroid storm, pheochromocytoma, autonomic epileptic seizures, sepsis and impending cerebral herniation.…”

“…In several traumatic brain injury-induced PAID syndrome, symptoms resolved as the intracranial pressure normalized. Alcohol neurolysis and botulinum toxin type A injection were also proposed as treatment options for intractable PAID [7].…”

Botulinum Toxin A Injection into the Subscapularis Muscle to Treat Intractable Hemiplegic Shoulder Pain

“…Botulinum toxin type A (BTX) has been widely used to treat many conditions including spasticity, dystonia, myoclonus, muscle spasm, myofascial pain syndrome, paroxysmal autonomic instability with dystonia, and autonomic overactivity syndromes [ 10 11 ]. BTX was recently introduced as a novel treatment option for a variety of pain syndromes including shoulder pain [ 12 13 14 ].…”