Paroxysmal Sympathetic Hyperactivity Complicated by Rhabdomyolysis and Acute Kidney Injury Following Spontaneous Pontine Hemorrhage.

Paroxysmal sympathetic hyperactivity (PSH) is a potentially life-threatening clinical syndrome characterized by sudden, episodic increases in sympathetic nervous system activity. While commonly described after traumatic brain injury, it is a rare and under-recognized complication of intracerebral hemorrhage (ICH). Diagnosis is challenging in the acute setting due to its nonspecific presentation and constellation of symptoms. The pathophysiology remains poorly understood, and no standardized diagnosis or treatment guidelines exist. We describe a case of a 50-year-old male patient with spontaneous pontine ICH who developed PSH within a week of admission, with hyperthermia, hypertension, tachycardia, and dystonic posturing. Despite multimodal therapy with bromocriptine, baclofen and clobazam, the patient developed complications of rhabdomyolysis likely from drug-refractory paroxysmal rigidity and acute kidney injury requiring dialysis. This case highlights the diagnostic and therapeutic challenges of PSH in neurocritical care, underscoring the necessity of heightened clinical suspicion, exclusion of mimics, and early individualized treatment to optimise outcomes.