Postictal pulmonary edema

Severe Subarachnoid Hemorrhage With Pulmonary Edema Successfully Treated by Intra-aneurysmal Embolization Using Guglielmi Detachable Coils. Two Case Reports

A 48-year-old male and a 39-year-old female presented with subarachnoid hemorrhage (SAH) due to ruptured anterior communicating artery aneurysms. Both patients were comatose on admission. Chest radiography disclosed pulmonary edema. They were conservatively treated under controlled ventilation, but cardiopulmonary dysfunction persisted over 2 days. The patients were then treated by intra-aneurysmal embolization with Guglielmi detachable coils (GDCs) 2 days after the onset. The postoperative courses were uneventful, and the patients showed full recovery from pulmonary edema and were discharged without neurological deficits. Neurogenic pulmonary edema is one of the serious complications of SAH, and is a leading cause of poor clinical outcome. The favorable outcomes of the present cases suggest that intra-aneurysmal embolization with GDCs is an excellent choice for the patients with severe aneurysmal SAH complicated with pulmonary edema, in whom conventional surgical treatment under general anesthesia is difficult to perform in the acute stage.

Evidence for a hydrostatic mechanism in human neurogenic pulmonary edema

STUDY OBJECTIVES

To identify the relative contribution of hydrostatic and permeability mechanisms to the development of human neurogenic pulmonary edema.

DESIGN

Retrospective review of patients with neurogenic pulmonary edema who had pulmonary edema fluid analysis.

SETTING

University hospital ICU.

PATIENTS

Twelve patients with neurogenic pulmonary edema in whom the associated neurologic condition was subarachnoid hemorrhage (n = 8, 67%), postcraniotomy (n = 2), and stroke (n = 2).

MEASUREMENTS

Protein concentration was measured from pulmonary edema fluid and plasma samples obtained shortly after the onset of clinical pulmonary edema.

RESULTS

The mechanism of pulmonary edema was classified according to the initial alveolar edema fluid to plasma protein concentration ratio. A hydrostatic mechanism (ratio < or = 0.65) was observed in seven patients, none of whom had cardiac failure or intravascular volume overload. Five patients had evidence for increased permeability (ratio > 0.70). Patients with a hydrostatic mechanism had better initial oxygenation (mean +/- SD PaO2/FIO2 [fraction of inspired oxygen] = 233 +/- 132) compared with patients with increased permeability (PaO2/FIo2 = 80 +/- 42), and oxygenation improved more rapidly in the hydrostatic patients. Overall mortality (58%) was high, but it was related to unresolved neurologic deficits, not to respiratory failure.

CONCLUSION

Many of our patients had a hydrostatic mechanism for neurogenic pulmonary edema. This is a novel observation in humans since prior clinical case reports have emphasized increased permeability as the usual mechanism for neurogenic pulmonary edema. These findings are consistent with pulmonary venoconstriction or transient elevation in left-sided cardiovascular pressures as contributing causes to the development of human neurogenic pulmonary edema.

Neurogenic pulmonary edema: case reports and review

Neurogenic pulmonary edema (NPE) is a relatively common though often subclinical complication of a variety of central nervous system insults (trauma, hemorrhage, seizures, etc.) in children and adults. The syndrome probably results from massive centrally mediated sympathetic discharge and generalized vasoconstriction, and often presents in the emergency department (ED). The symptoms are likely to be mistaken for aspiration pneumonia. Treatment consists of ventilatory support, including positive end-expiratory pressure, and aggressive measures to reduce intracranial pressure. We present four cases of NPE and review its recognition and emergent management.

Recurrent postictal pulmonary edema: a case report and review of the literature

A 37-year-old woman with a post-traumatic seizure disorder had four well-documented episodes of postictal acute pulmonary edema and respiratory failure. Subtherapeutic blood concentrations of phenytoin were documented on each admission. Each episode followed one or more grand mal seizures and was characterized by the development of diffuse nodular-appearing alveolar infiltrates, tachypnea, and severe hypoxemia that rapidly resolved with supportive therapy. There was no evidence of gastric acid aspiration, acute lung infection, or underlying heart or lung disease. To determine the frequency of postictal pulmonary edema in our institution, we reviewed the clinical records and chest roentgenograms of 45 consecutive patients who were admitted to our emergency room following a well-documented grand mal seizure. Only one patient (described in this report) had chest roentgenographic evidence of pulmonary edema. A review of the English literature revealed only 11 reported cases of postictal pulmonary edema since 1965 and a total of 42 episodes in 27 patients since 1908. There were no clearly documented cases of postical pulmonary edema following electroconvulsive therapy in 18 published reports totaling more than 38,000 subjects. Our findings suggest that while postictal pulmonary edema may occur repeatedly in the same patient, the overall frequency of this complication is low.

Neurogenic pulmonary edema in unexpected, unexplained death of epileptic patients

Eight cases of unexpected, unexplained death in young ambulatory epileptics were examined postmortem with special attention to the heart and lungs. Lung weights uniformly exceeded the expected value, with gross evidence of hemorrhagic pulmonary edema. Microscopic examination revealed moderate to severe pulmonary edema with protein-rich fluid as well as alveolar hemorrhage. There was no evidence of recent or old myocardial disease. Although death due to a seizure is usually thought to be almost instantaneous, the neurogenic pulmonary edema exemplified by these cases takes time to develop and may be remediable. The high frequency of absent or non-therapeutic anticonvulsant levels at the time of death in these patients may play a role in a possible centrally mediated adrenergic cause of neurogenic pulmonary edema and ventricular arrhythmia.