Disclosures: Gabrielle T. Goodlin, MD: No financial relationships or conflicts of interest

Case Diagnosis: Paroxysmal sympathetic hyperactivity (PSH) secondary to anoxic brain injury refractory to pharmacological management.

Case Description or Program Description: A 14-month-old boy presented with anoxic brain injury (ABI) secondary to submersion and cardiac arrest with a down time of 25-30 minutes. Approximately one week following submersion injury, the patient developed worsening episodes of agitation that were consistent with PSH. These episodes were refractory to medication and associated with elevated creatine kinase levels to 4,800 U/L. The patient was transferred to the pediatric intensive care unit (PICU) for further management. Multiple medications were tried – including precedex (dexmedetomidine hydrochloride), methadone, diazepam, lorazepam, clonidine, baclofen, bromocriptine, propranolol, gabapentin, and melatonin – however the PSH episodes continued to be refractory to pharmacological treatment for over 2 weeks. CT Head and MRI Brain were unremarkable. 24-hour EEG showed no focal findings. The decision was made to trial epidiolex (cannabidiol) at a dose of 2mg/kg.

Setting: Acute Care Pediatric Hospital

Assessment/Results: The patient’s hypertonicity improved following the initiation of epidiolex. The dose was increased to 5mg/kg four days later with continued improvement in agitation and tone. The PSH episodes mostly resolved after approximately five weeks. The patient was weaned off epidiolex over the course of 10 days with the assistance of inpatient pharmacy six weeks after initial treatment was started.

Discussion (relevance): Preclinical studies have investigated the neuroprotective effects of cannabidiol after hypoxic-ischemic brain injuries in animal models and found that cannabidiol protects neuronal and glial cells from excitotoxicity and oxidative stress. A clinical trial is currently underway in the European Union investigating the use of cannabidiol in neonates, however there is little-to-no reported use for hypoxic brain injuries in older pediatric populations.

Conclusions: Off-label use of Epidiolex (Cannabidiol) may be beneficial in the treatment of refractory PSH as a result of ABI sequelae in the pediatric populations.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/use-of-epidiolex-cannabidiol-for-management-of-paroxysmal-sympathetic-hyperactivity-in-a-toddler-with-anoxic-brain-injury-a-case-report/