Neuroleptic malignant syndrome from central nervous system insult: 4 cases and a novel treatment strategy

Clinical article

Restricted access

Neuroleptic malignant syndrome (NMS) is a potentially life-threatening entity characterized by hyperthermia, autonomic deregulation, decreased mental status, increased muscle tone, and, frequently, by renal failure due to rhabdomyolysis. Classically, it follows administration of antipsychotic medication.

The authors report on 4 patients (2 children and 2 adults) in whom NMS was diagnosed after a CNS insult. No patient was receiving antipsychotic medication. The patients' hospital and clinic charts, radiographic data, and follow-up telephone conversations were reviewed retrospectively.

All 4 patients met diagnostic criteria for NMS. Three patients presented with shunt failure, and 1 patient had undergone a functional hemispherectomy 2 days earlier. One patient with shunt failure received the diagnosis retrospectively. An endoscopic third ventriculostomy alleviated his shunt failure and he remains free of NMS. The other 2 patients underwent treatment for shunt failure, but NMS remained. These 2 patients and the one who had undergone hemispherectomy underwent a trial of intrathecal baclofen, and the NMS resolved. Subsequently, an intrathecal baclofen infusion device was placed in all 3 patients, and the NMS resolved. The 2 patients in shunt failure had a lumbar intrathecal baclofen infusion device. The patient who had undergone hemispherectomy had an intracranial baclofen catheter.

Neuroleptic malignant syndrome is a rare, life-threatening disorder that can occur without the administration of neuroleptic medications. Alleviation of any CNS insult is the first order of treatment. Some patients with persistent symptoms of NMS may benefit from intrathecal delivery of baclofen.

Abbreviations used in this paper: ETV = endoscopic third ventriculostomy; ICP = intracranial pressure; NMS = neuroleptic malignant syndrome; VP = ventriculoperitoneal.

Article Information

Address correspondence to: Harold L. Rekate, M.D., c/o Neuroscience Publications Office, St. Joseph's Hospital and Medical Center, 350 West Thomas Road, Phoenix, Arizona 85013. email:

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Case 3. Axial CT scans of the head obtained before (left) and after (right) shunt failure, demonstrating ventriculomegaly.

  • View in gallery

    Case 4. Preoperative coronal (left) and axial (right) MR images showing the extensive encephalomalacia of the right hemisphere thought to underlie the patient's intractable epilepsy.

  • View in gallery

    Case 4. Images obtained after insertion of the intrathecal baclofen infusion device. Postoperative CT scan (A) showing the intracranial catheter. Lateral scout radiograph (B) showing the course and entry point of the catheter (arrow), and anteroposterior flat plate (C) showing the position of the pump and course of the extracranial catheter.



Albright AL: Intraventricular baclofen infusion for dystonia. Report of two cases. J Neurosurg 105:71742006


Albright AL: Long-term intraventricular baclofen infusion in beagles. J Neurosurg 107:2252272007


Bhanushali MJTuite PJ: The evaluation and management of patients with neuroleptic malignant syndrome. Neurol Clin 22:3894112004


Caroff SNMann SC: Neuroleptic malignant syndrome. Med Clin North Am 77:1852021993


Caroff SNMann SCMcCarthy MNaser JRynn MMorrison M: Acute infectious encephalitis complicated by neuroleptic malignant syndrome. J Clin Psychopharmacol 18:3493511998


Chiodo LAAntelman SM: Electroconvulsive shock: progressive dopamine autoreceptor subsensitivity independent of repeated treatment. Science 210:7998011980


Coffey RJEdgar TSFrancisco GEGraziani VMeythaler JMRidgely PM: Abrupt withdrawal from intrathecal baclofen: recognition and management of a potentially life-threatening syndrome. Arch Phys Med Rehabil 83:7357412002


Delay JPichot PLemperiere TElissalde BPeigne F: A non-phenothiazine and non-reserpine major neuroleptic, haloperidol, in the treatment of psychoses. Ann Med Psychol (Paris) 118:1451521960


Douglas AFWeiner HLSchwartz DR: Prolonged intrathecal baclofen withdrawal syndrome. Case report and discussion of current therapeutic management. J Neurosurg 102:113311362005


Duhon BSMacDonald JD: Infusion of intrathecal baclofen for acute withdrawal. Technical note. J Neurosurg 107:8788802007


Heiman-Patterson TD: Neuroleptic malignant syndrome and malignant hyperthermia. Important issues for the medical consultant. Med Clin North Am 77:4774921993


Levenson JL: Neuroleptic malignant syndrome. Am J Psychiatry 142:113711451985


Meythaler JMGuin-Renfroe SHadley MN: Continuously infused intrathecal baclofen for spastic/dystonic hemiplegia: a preliminary report. Am J Phys Med Rehabil 78:2472541999


Mills KC: Serotonin syndrome. A clinical update. Crit Care Clin 13:7637831997


Pilo L: Neuroleptic malignant syndrome in organic brain disease and physical illness. Singapore Med J 31:3113131990


Rekate HLNadkarni TDWallace D: The importance of the cortical subarachnoid space in understanding hydrocephalus. J Neurosurg Pediatr 2:1112008


Rosebush PIStewart TMazurek MF: The treatment of neuroleptic malignant syndrome. Are dantrolene and bromocriptine useful adjuncts to supportive care?. Br J Psychiatry 159:7097121991


Samson-Fang LGooch JNorlin C: Intrathecal baclofen withdrawal simulating neuroepileptic malignant syndrome in a child with cerebral palsy. Dev Med Child Neurol 42:5615652000


Scheftner WAShulman RB: Treatment choice in neuroleptic malignant syndrome. Convuls Ther 8:2672791992


Trollor JNSachdev PS: Electroconvulsive treatment of neuroleptic malignant syndrome: a review and report of cases. Aust N Z J Psychiatry 33:6506591999


Turner MRGainsborough N: Neuroleptic malignant-like syndrome after abrupt withdrawal of baclofen. J Psychopharmacol 15:61632001


Wielosz M: Increased sensitivity to dopaminergic agonists after repeated electroconvulsive shock (ECS) in rats. Neuropharmacology 20:9419451981




All Time Past Year Past 30 Days
Abstract Views 20 20 4
Full Text Views 36 36 9
PDF Downloads 40 40 11
EPUB Downloads 0 0 0


Google Scholar