Case Presentation: A 57-year-old male with history of C5-6 spinal cord injury (SCI) presented with recurrent episodes of sweating, flushing, headache, and hypertensive episodes over the past week, with concern for autonomic dysreflexia (AD). The patient is tetraplegic following traumatic SCI 38 years ago associated with remote episodic AD due to neurogenic bladder and adynamic ileus. He reports a growing pressure ulcer over the right sacroiliac joint for the past 6 weeks. CT of the hip was consistent with early decubitus ulcer. Efforts at pressure management and bowel hygiene were unsuccessful in ameliorating AD and PM&R was consulted. Bowel evacuation and empiric treatment for bacteriuria saw no improvement. Wound care, orthopedics and plastics consults agreed with current management. On hospital day (HOD) 8, the patient experienced vision loss, expressive aphasia, associated with systolic BP >200 (baseline 90/50) when toileting. A brain attack was called and head CT/MRI showed no acute intracranial abnormality. Vision returned while mild expressive aphasia persisted. Despite adherence to protocols, AD did not resolve and the patient was transferred to a specialty SCI facility.
Discussion: Autonomic Dysreflexia (AD) is a hypertensive emergency occurring in up to 70% of patients with SCI lesions at or rostral to T6. In up to 50% of cases the initial episode occurs 3-6 months post-SCI (1). Hypertensive responses, as in this patient, are caused by afferent “pain” signals and can result in blood pressures >200/100, leading to retinal hemorrhage and stroke (2,3). Due to SCI, efferent modulation of splanchnic vascular tone is lost and unable to compensate for hyperactive afferent neuromodulation from noxious stimuli, such as bladder or bowel distention (4). Treatment requires identification and removal of the offensive stimulus. Common causes include bladder distension, fecal retention, pressure sores, infection, ingrown toenail, and occult visceral pathology (5). As in this patient, treatment can require extensive workup and presents a diagnostic challenge due to the lack of nociception in these patients. Experimental interventions are focused on prophylactic and abortive anti-hypertensive therapy. When treating AD hypertension, the risk for hypoperfusion is high following resolve as patients have low mean arterial pressures with average BP in the 90s/50s. Medical procedures, such as seminal fluid collection for fertility procedures, labor, delivery, or other surgery are at high-risk for exacerbation. Immediate measures should be taken to reduce BP via orthostatic reduction: elevate the head, lower the legs, remove sources of pressure peripherally, followed by identification and removal of the offensive agent. This focus on etiologic management has resulted in a paucity of evidence-based approaches for managing recurrent idiopathic episodes.
Conclusions: Autonomic dysreflexia – Loss of coordinated autonomic control of heart rate and blood pressure, is a medical emergency that presents a diagnostic and therapeutic challenge and occurs in up to 70% of spinal cord injury (SCI) patients. Lack of nociception in SCI patients below the level of the lesion presents a diagnostic challenge. Recognition of dysreflexia in SCI patients is critical to rapid diagnosis and symptomatic management until noxious etiology can be identified. Further evidenced-based approaches to idiopathic AD management are needed.