The DOI matches its Crossref record; 12 of the 13 references it cites were found in a registry or an index; none of the 8 sources its claims cite is checked for support yet.
Paroxysmal Sympathetic Hyperactivity in Pediatric Acquired Brain Injury: An Under-Recognized Entity
Open accessAbstract
Paroxysmal sympathetic hyperactivity (PSH) is a less-known neurologic emergency that can be life-threatening. It is a form of extreme autonomic dysregulation leading to multiple episodes of sympathetic hyperactivity. The pathogenesis of this interesting entity is yet to be fully understood. It presents as unexplained tachycardia, hypertension, and sometimes hyperthermia. Poor awareness of this fact leads to unnecessary workup to look for the cause of fever and interventions such as change of antibiotics. If it is not treated adequately, it can even cause complications like arrhythmias that can be fatal at times. PSH secondary to acquired brain injury is better known in adults, but there are scarce reports in children. We describe six cases of PSH in children with acquired brain injury – four secondary to traumatic brain injury and two secondary to neurologic infection (one with bacterial meningitis and the other one with viral meningoencephalitis). PSH can be seen in non-traumatic brain injury cases like meningitis. Due to a lack of awareness about this common but under-recognized entity, it is seldom diagnosed and treated. Early detection and treatment can be life-saving and improve patient outcomes. Earlier onset may be associated with poorer outcomes and mortality.
Overview
CoChat Summary
TL;DR
This case series describes six children with paroxysmal sympathetic hyperactivity (PSH) after acquired brain injury, including four with traumatic brain injury and two with neurologic infection. It argues that PSH is under-recognized in children, can occur within the first week, and that earlier onset may be associated with poorer outcomes and mortality.
Key findings
- Six children aged 10 months to 17 years (two male, four female) were diagnosed with PSH: four had traumatic brain injury, one had staphylococcal meningitis, and one had herpes simplex virus-1 encephalitis. All had tachycardia, five of six had hypertension, four had dystonia, and all had PSH onset within the first week of illness.
- PSH-AM scores ranged from 11 to 16, all within the “possible” PSH range (8–16). Both children with onset on day 2 died by the end of the first ICU week, with death attributed to cardiovascular instability–PSH; the other four improved.
- CRP was checked in four cases and was normal in three, with a declining trend in the fourth, suggesting that a normal CRP during fever may help differentiate PSH from infectious fever.
- PSH occurred after non-traumatic acquired brain injury such as meningitis and encephalitis, not only after traumatic brain injury.
Methods
- Case series of six children enrolled from January 2022 to June 2024; MRI was performed in all cases, and the PSH-assessment measure (PSH-AM) was applied to each case.
- The authors assessed number of symptoms per child, number of episodes per day, and outcome; written parental consent and institutional ethics committee approval were obtained.
Limitations
- Stated: there is a lack of pediatric PSH data, no comparative drug trials exist, treatment is not standardized, diagnostic criteria are not firmly established, and future studies with larger sample sizes are needed.
- Evident: this is a six-patient case series without a control group, so the suggested association between earlier onset and mortality cannot establish causality; treatment was heterogeneous (gabapentin, baclofen, propranolol, clonidine), limiting comparison.
- Evident: the text inconsistently reports hypertension frequency, stating “five out of six” in the results/abstract but “four of the five children” in the discussion.
Model-written summary. Check it against the paper before relying on it.
Integrity signals
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Verification
Claims the paper makes
0 Valid · 0 Not valid · 8 Not checked · 13 Own results and interpretations
In the paper
“However, this information is crucial and may indicate that PSH in children may be different from that in adults, as suggested by the very early onset in our cases compared to cases in adult literature.[12]”
§ Paroxysmal Sympathetic Hyperactivity in Pediatric Acquired Brain Injury: An Under-Recognized Entity > Discussion
What the sources say
- Not checked yetcites [12] Verma R Giri P Rizvi I Paroxysmal sympathetic hyperactivity in neurological critical care Indian J Crit Care Med 2015 19 34 7 25624648 PMC4296409
hedgedstates an association- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Normal CRP value during the time of fever can be a clue that helps in differentiating PSH from fever due to infectious etiology.”
- Also stated in: § Discussion · hedged
“Estimation of CRP may help in differentiating fever due to infectious cause from that due to PSH as seen in three of our cases which had values within the normal range.”
§ Paroxysmal Sympathetic Hyperactivity in Pediatric Acquired Brain Injury: An Under-Recognized Entity > Results
plainstates an associationn = 3- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
- Also stated in: § Discussion · hedged
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“PSH can be seen in non-traumatic brain injury cases like meningitis.”
- Also stated in: § Conclusion · hedged
“Though it is mostly seen with TBI, it may be seen in other cases of acquired brain injury such as meningitis with or without encephalitis.”
§ Paroxysmal Sympathetic Hyperactivity in Pediatric Acquired Brain Injury: An Under-Recognized Entity > Abstract
plainstates a cause- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
- Rests on an assumption not shown here.
- Also stated in: § Conclusion · hedged
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“This could suggest that early onset may be associated with poor outcomes and mortality.”
- Also stated in: § Conclusion · hedged
“The earlier the onset of PSH features, the higher may be the possibility of adverse outcomes.”
§ Paroxysmal Sympathetic Hyperactivity in Pediatric Acquired Brain Injury: An Under-Recognized Entity > Results
hedgedstates an associationn = 6- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
- Also stated in: § Conclusion · hedged
In the paper
“An expert consensus by Baguley et al.[7] suggested that the sum of two components of PSH-AM scale, namely the clinical features severity scale and the diagnosis likelihood tool, helps in predicting the probability of PSH [Table 2].”
§ Paroxysmal Sympathetic Hyperactivity in Pediatric Acquired Brain Injury: An Under-Recognized Entity > Discussion
What the sources say
- Not checked yetcites [7] Baguley IJ Perkes IE Fernandez-Ortega J-F RabinsteinAA, Dolce G Hendricks HT Paroxysmal sympathetic hyperactivity after acquired brain injury: Consensus on conceptual definition, nomenclature, and diagnostic criteria J Neurotrauma 2014 31 1515 20 24731076
hedgedstates an association- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
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- Probably not a substantial claim. 3
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
Each contradiction between two passages listed here was confirmed by an independent check.
Rated minor: it would not touch a result — a value no result rests on, a p-value that stays on the same side of the significance level, or a conflict that is clerical, resolved elsewhere in the paper, or outside its own findings.
In the paper
§ Paroxysmal Sympathetic Hyperactivity in Pediatric Acquired Brain Injury: An Under-Recognized Entity > Results
“five out of the six cases had hypertension”
§ Paroxysmal Sympathetic Hyperactivity in Pediatric Acquired Brain Injury: An Under-Recognized Entity > Discussion
“In our cases, all had tachycardia and four of the five children had hypertension.”
Citations
Cites
Baguley, I. J., Perkes, I. E., Fernández-Ortega, J. F., Rabinstein, A. A., Dolce, G., Hendricks, H. T., & for the Consensus Working Group (2014) · Journal of Neurotrauma · doi:10.1089/neu.2013.3301 · Cited by 367
Paroxysmal sympathetic hyperactivity: the storm after acute brain injury
Meyfroidt, G., Baguley, I. J., & Menon, D. K. (2017) · The Lancet Neurology · doi:10.1016/s1474-4422(17)30259-4 · Cited by 336
Baguley, I. J., Slewa‐Younan, S., Heriseanu, R., Nott, M. T., Mudaliar, Y., & Nayyar, V. (2007) · Brain Injury · doi:10.1080/02699050701687375 · Cited by 157
Identification and Management of Paroxysmal Sympathetic Hyperactivity After Traumatic Brain Injury
Zheng, R., Lei, Z.-Q., Yang, R., Huang, G., & Zhang, G. (2020) · Frontiers in Neurology · doi:10.3389/fneur.2020.00081 · Cited by 123
Paroxysmal sympathetic hyperactivity in severe traumatic brain injury
Mathew, M. J., Deepika, A., Shukla, D. P., Devi, B. I., & Ramesh, V. J. (2016) · Acta Neurochirurgica · doi:10.1007/s00701-016-2934-x · Cited by 76
Pozzi, M., Conti, V., Locatelli, F., Galbiati, S., Radice, S., Citerio, G., Clementi, E., & Strazzer, S. (2014) · Journal of Head Trauma Rehabilitation · doi:10.1097/htr.0000000000000084 · Cited by 47
Paroxysmal sympathetic hyperactivity in neurological critical care
Rizvi, I., Verma, R. K., & Giri, P. (2015) · Indian Journal of Critical Care Medicine · doi:10.4103/0972-5229.148638 · Cited by 34
Farias‐Moeller, R., Carpenter, J. L., Dean, N., & Wells, E. M. (2015) · Neurocritical Care · doi:10.1007/s12028-015-0124-y · Cited by 25
Paroxysmal sympathetic hyperactivity: An entity to keep in mind
Godoy, D. A., Panhke, P., Suárez, P. D. G., & Murillo-Cabezas, F. (2018) · Medicina Intensiva (English Edition) · doi:10.1016/j.medine.2018.10.003 · Cited by 23
Hiperactividad simpática paroxística: una entidad que no debería pasar desapercibida
Godoy, D. A., Panhke, P., Suárez, P. D. G., & Murillo-Cabezas, F. (2017) · Medicina Intensiva · doi:10.1016/j.medin.2017.10.012 · Cited by 21
Cited by
Li, M., Wei, Y., Cai, Z., Wang, L., Guo, S., Cao, J., Tang, H., & Wang, L. (2026) · Frontiers in Neuroscience · doi:10.3389/fnins.2026.1935805
Metadata
- Authors
- Kamate, M., Koppad, B., & Thanuja, B.
- Affiliations
- Jawaharlal Nehru Medical College (IN)
- Department of Pediatric Neurology, Karnataka Lingayat Education Academy of Higher Education and Research University’s Jawaharlal Nehru Medical College, Belagavi, Karnataka, India
- Corresponding author
- Kamate, Mahesh
- ORCID
- Kamate, Mahesh
- Venue
- Annals of Indian Academy of Neurology
- Published
- 2025-01
- Volume
- 28
- Issue
- 1
- Pages
- 99-103
- ISSN
- 0972-2327 (ISSN-L)
- 1998-3549
- PMC
- PMC11892971
- OpenAlex
- W4406436770
- Semantic Scholar
- 148c3e81e5c420609afcc667198e50be72ad03c4
- Cited by
- 1
- References
- 12
- Citations by year
- 2026: 1
- FWCI
- 0.50
- Type
- journal article
- Language
- en
- Open access
- diamond
- doi.org
- Licence
- Locations
- Annals of Indian Academy of Neurology (publishedVersion, cc-by-nc-sa)
- PubMed Central (publishedVersion, cc-by-nc-sa)
- Europe PMC (PubMed Central) (publishedVersion, cc-by-nc-sa)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Topics
- Health Sciences › Medicine › Clinical Neurology › Traumatic Brain Injury and Neurovascular Disturbances
- Health Sciences › Medicine › Clinical Neurology › Traumatic Brain Injury Research
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Takotsubo Cardiomyopathy and Associated Phenomena
- Keywords
- paroxysmal sympathetic hyperactivity, acquired brain injury, pediatric patients, traumatic brain injury, bacterial meningitis, viral meningoencephalitis, autonomic dysfunction, tachycardia, hypertension, hyperthermia, cardiac arrhythmias, neurological emergencies, under-recognition
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- CoChat. (2026). Citation check: Paroxysmal Sympathetic Hyperactivity in Pediatric Acquired Brain Injury: An Under-Recognized Entity. https://app.cochat.ai/papers/10.4103/aian.aian_549_24
- The paper
- Kamate, M., Koppad, B., & Thanuja, B. (2025). Paroxysmal Sympathetic Hyperactivity in Pediatric Acquired Brain Injury: An Under-Recognized Entity. Annals of Indian Academy of Neurology. https://doi.org/10.4103/aian.aian_549_24
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