Neurogenic pulmonary edema associated with ruptured intracranial aneurysm: case report

Distant Organ Damage in Acute Brain Injury

Acute brain injuries pose a great threat to global health, having significant impact on mortality and disability. Patients with acute brain injury may develop distant organ failure, even if no systemic diseases or infection is present. The severity of non-neurologic organs' dysfunction depends on the extremity of the insult to the brain. In this comprehensive review we sought to describe the organ-related consequences of acute brain injuries. The clinician should always be aware of the interplay between central nervous system and non-neurological organs, that is constantly present. Cerebral injury is not only a brain disease, but also affects the body as whole, and thus requires holistic therapeutical approach.

Endovascular Therapy for Aneurysmal Subarachnoid Hemorrhage Complicated by Neurogenic Pulmonary Edema and Takotsubo-Like Cardiomyopathy: A Report of Ten Cases

Objective:

Patients sustaining aneurysmal subarachnoid hemorrhage (aSAH) can be further complicated by neurogenic pulmonary edema (NPE) and Takotsubo-like cardiomyopathy (TCM) with dismal outcomes. The present study aimed to validate the efficacy of endovascular therapy for patients with aSAH complicated by NPE and TCM.

Materials and Methods:

Patients who were diagnosed with aSAH complicated by NPE and TCM and treated by endovascular therapy were retrospectively evaluated.

Results:

In the past 5 years, a total of ten female patients with aSAH were also diagnosed with NPE and TCM. Six of the ten were cases with high-grade aSAH (Hunt and Hess Grades IV and V), whereas four were low-grade aSAH (Grades II and III). The locations of ruptured aneurysms were the internal carotid-posterior communicating artery junctional site in five patients, the anterior communicating artery in two, the vertebral artery in two, and the middle cerebral artery in one. These aneurysms were successfully embolized by endovascular therapy without any procedure-associated complications. The clinical outcome measure at 6 months after discharge on the Modified Rankin Scale was found to be 0 in four patients, 1 in two, 3 in one, and 5 in three.

Conclusions:

Endovascular therapy can be a feasible, alternative measure for the treatment of patients with high-grade aSAH who also have NPE and TCM.

Neurogenic pulmonary edema due to ventriculo-atrial shunt dysfunction: a case report

BACKGROUND AND OBJECTIVES

Pulmonary edema is caused by the accumulation of fluid within the air spaces and the interstitium of the lung. Neurogenic pulmonary edema is a clinical syndrome characterized by the acute onset of pulmonary edema following a significant central nervous system insult. It may be a less-recognized consequence of raised intracranial pressure due to obstructive hydrocephalus by blocked ventricular shunts. It usually appears within minutes to hours after the injury and has a high mortality rate if not recognized and treated appropriately.

CASE REPORT

We report a patient with acute obstructive hydrocephalus due to ventriculo-atrial shunt dysfunction, proposed to urgent surgery for placement of external ventricular drainage, who presented with neurogenic pulmonary edema preoperatively. She was anesthetized and supportive treatment was instituted. At the end of the procedure the patient showed no clinical signs of respiratory distress, as prompt reduction in intracranial pressure facilitated the regression of the pulmonary edema.

CONCLUSIONS

This report addresses the importance of recognition of neurogenic pulmonary edema as a possible perioperative complication resulting from an increase in intracranial pressure. If not recognized and treated appropriately, neurogenic pulmonary edema can lead to acute cardiopulmonary failure with global hypoperfusion and hypoxia. Therefore, awareness of and knowledge about the occurrence, clinical presentation and treatment are essential.

Takotsubo cardiomyopathy in aneurysmal subarachnoid hemorrhage: Institutional experience and literature review

OBJECTIVES

To review the current practice in the diagnosis, monitoring and management of TCM in SAH patients at our tertiary referral institution and the relevant literature, and to evaluate the effect of certain treatment modalities on the outcome of those patients.

PATIENTS AND METHODS

A retrospective institutional chart review of 800 patients with aneurysmal SAH from 2007 to 2014. Eighteen patients were identified to have both aneurysmal SAH and TCM based on echocardiogram. Demographic data, clinical parameters, radiographic findings, treatment modalities, and laboratory results were analyzed.

RESULTS

The incidence of typical TCM in our patients was 2.2%. Mortality rate of TCM in SAH was 22% compared to the total mortality rate of all non-traumatic SAH patients of 15% in our institution over the same time period. Use of beta blockers prior to or after the diagnosis of TCM did not seem to affect their outcome. Majority of patients (61%) were on vasopressors prior to the diagnosis of TCM. Of those, 73% had good outcomes. Even after the diagnosis of TCM, good outcomes were observed in 6 of 7 patients who remained on vasopressors.

CONCLUSION

Despite the general agreement on the importance of the avoidance of vasopressors in TCM, our experience showed that the use of vasopressors is safe in these patients. The use of beta blockers in our patients was not associated with significantly better outcomes despite multiple previous reports on beta blocker usage in TCM.

Early endovascular treatment of aneurysmal subarachnoid hemorrhage complicated by neurogenic pulmonary edema and Takotsubo-like cardiomyopathy

Aneurysmal subarachnoid hemorrhage (SAH) may be associated with acute cardiopulmonary complications, like neurogenic pulmonary edema (NPE) and Takotsubo-like cardiomyopathy (TCM). These dysfunctions seem to result from a neurogenically induced overstimulation of the sympathetic nervous system through the brain-heart connection and often complicate poor grade aneurysmal SAH. The optimal treatment modality and timing of intervention in this clinical setting have not been established yet. Early endovascular therapy seems to be the fitting treatment in this particular group of patients, in which surgical clipping is often contraindicated due to the added risk of craniotomy. Herein we describe the case of a woman admitted to the emergency department with aneurysmal SAH complicated by NPE-TCM, in which early endovascular coiling was successfully performed. Our case, characterized by a favorable outcome, further supports the evidence that early endovascular treatment should be preferred in this peculiar clinical scenario.

The systemic implications of aneurysmal subarachnoid hemorrhage

Aneurysmal subarachnoid hemorrhage (SAH) is analogous to a pathophysiological watershed, disrupting brain integrity and function and precipitating an array of systemic derangements including cardiovascular, respiratory, endocrine, hematological, and immune dysfunction. Extracerebral organ dysfunction is closely linked to the magnitude of the primary neurological insult, suggesting neurogenic, neuroendocrine and neuroimmunomodulatory mechanisms. Systemic organ involvement is associated with increased mortality and neurological impairment, even after adjustment for other outcome predictors such as the severity of the initial neurological injury. This may be a reflection of secondary brain injury precipitated by hypoxemia, circulatory failure, fever, or hyperglycemia, all of which have been linked to adverse clinical outcomes. Interventions to avert or reverse these and other perturbations need to be tested in clinical trials as they represent opportunities to improve survival and neurological recovery in patients with SAH.

Early embolization for ruptured aneurysm in acute stage of subarachnoid hemorrhage with neurogenic pulmonary edema

SUMMARY

Four cases of ruptured aneurysmal subarachnoid hemorrhage (SAH) presented with severe neurogenic pulmonary edema (NPE). On admission, two patients were grade IV and two were grade V according to Hunt and Hess grading. All patients needed respiratory management with the assistance of a ventilator. Three of them underwent endovascular treatment for the ruptured aneurysms within three days from onset after ensuring hemodynamic stability. Immediately after the endovascular treatment, lumbar spinal drainage was inserted in all the patients. The pulmonary edema findings disappeared rapidly after the respiratory management. The results were good recovery in two, and moderate disability in two. We concluded that early embolization of ruptured aneurysm and placement of spinal drainage is a satisfactory option for severe SAH with NPE.

Neurogenic Pulmonary Edema Due to Traumatic Brain Injury: Evidence of Cardiac Dysfunction

• Background Acute neurogenic pulmonary edema, a common and underdiagnosed clinical entity, can occur after virtually any form of injury of the central nervous system and is a potential early contributor to pulmonary dysfunction in patients with head injuries.

• Objective To explore myocardial function in patients with evident neurogenic pulmonary edema after traumatic head injury.

• Methods During a 1-year period in a university hospital in Sfax, Tunisia, information was collected prospectively on patients admitted to the 22-bed intensive care unit because of isolated traumatic head injury who had neurogenic pulmonary edema. Data included demographic information, vital signs, neurological status, physiological status, and laboratory findings. All of the patients had computed tomography and plain radiography of the neck and determination of cardiac function.

• Results All 7 patients in the sample had cardiac dysfunction. Evidence of myocardial damage was confirmed by echocardiography in 3 patients, pulmonary artery catheterization in 3 patients, and/or postmortem myocardial biopsy in 4 patients. Echocardiography studies, repeated 7 days after the initial study in one patient and 90 days afterward in another, showed complete improvement in wall motion, with a left ventricular ejection fraction of 0.65.

• Conclusion All patients who had neurogenic pulmonary edema due to traumatic head injury had myocardial dysfunction. The mechanisms of the dysfunction were multiple. The great improvement in wall motion seen in 2 patients indicated the presence of a stunned myocardium. Further studies are needed to understand the mechanisms of this cardiac dysfunction.

Extracerebral organ dysfunction in the acute stage after aneurysmal subarachnoid hemorrhage

In patients with aneurysmal subarachnoid hemorrhage (SAH), secondary complications are an important cause of morbidity and case fatality. Delayed cerebral ischemia and hydrocephalus are important intracranial secondary complications. Potentially treatable extracranial complications are also frequently observed, and some are related to the occurrence of delayed cerebral ischemia and outcome. In addition to the occurrence of an inflammatory response and metabolic derangements, cardiac and pulmonary complications are the most common extracranial complications. This article provides an overview of the most common extracranial complications in patients with SAH and describes their effects on outcome and delayed cerebral ischemia.

Terson's Syndrome as the Initial Symptom of Subarachnoid Hemorrhage Caused by Ruptured Vertebral Artery Aneurysm-Case Report-

A 61-year-old male initially presented to the ophthalmology department complaining of sudden visual loss. Fundus photography and ultrasonography followed by computed tomography identified Terson's syndrome caused by subarachnoid hemorrhage (SAH). Cerebral angiography revealed a dissecting aneurysm of the left vertebral artery. Other than obtunded visual acuity, his neurological examination was normal and he denied any headache. He was treated conservatively with pain and blood pressure control. He complained of headache associated with rerupture of the aneurysm on day 5. The patient died of rerupture on day 14. The clinical course of this patient indicates that Terson's syndrome may occur without sudden increase of intracranial pressure. Terson's syndrome may occur as a rare initial clinical sign of SAH caused by ruptured cerebral aneurysm.

Early myocardial dysfunction following subarachnoid haemorrhage

Like systolic dysfunction (SD), diastolic dysfunction (DD) has recently been proposed as a contributing factor in haemodynamic instability and in the genesis of pulmonary oedema, but its occurrence in subarachnoid haemorrhage (SAH) patients has not been described. Following aneurysmal SAH, three patients arrived at our institution with haemodynamic instability requiring vasoactive drugs and with pulmonary oedema. Transoesophageal echocardiographic study during aneurysm surgery documented mild to severe left ventricular SD and DD. Right ventricular SD and DD were also present. Documented biventricular systolic and diastolic myocardial dysfunctions may contribute to haemodynamic instability and pulmonary oedema following SAH due to intracranial aneurysmal rupture.

Cerebellar haemorrhage as a cause of neurogenic pulmonary edema - case report

The neurogenic pulmonary edema is a rare clinical situation caused by an imbalance characterized by an excessive sympathetic outflow. It is observed mostly in young patients, is associated with brain or spinal cord haemorrhage, trauma, tumours or infections and is usually fatal. A case of neurogenic pulmonary edema in a 27-year-old woman is presented, caused by a cerebellar haemorrhage due to a vermian and paravermian arteriovenous malformation rupture. The vermian and hemispheric haemorrhage injuring the sub-lobule IX-b of the uvula induced a disruption of both carotid baroreceptor and chemoreceptor reflexes control mechanisms. Medical treatment with controlled ventilation, PEEP, diuretics and morphine reverted the pulmonary edema. After surgical treatment of the haemorrhage and cerebellar AVM the patient recovered to an almost normal social and professional life. The cerebellar lesion induced a temporary vermian sub lobule IX-b dysfunction that was responsible for the sympathetic storm that evoked the neurogenic pulmonary edema.

Pulmonary Complications of Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE

Pulmonary complications challenge the medical management of patients who have sustained aneurysmal subarachnoid hemorrhage (SAH). We assessed the frequency and types of pulmonary complications after aneurysmal SAH and analyzed the impact of pulmonary complications on patient outcome.

METHODS

We reviewed the records of all patients with acute SAH treated at our institution between 1990 and 1997. Three hundred five consecutive patients with an aneurysmal hemorrhage source documented by angiography and treated within 7 days of ictus were analyzed. Outcomes at longest follow-up (mean, 16 mo) were measured by use of the Glasgow Outcome Scale.

RESULTS

Pulmonary complications were documented in 66 patients (22%). The pulmonary complications were nosocomial pneumonia in 26 patients (9%), congestive heart failure in 23 (8%), aspiration pneumonia in 17 (6%), neurogenic pulmonary edema in 5 (2%), pulmonary embolus in 2 (<1%), and other pulmonary disorders in 4 (1%); 11 patients had two pulmonary complications. The incidence of symptomatic vasospasm was greater in patients with pulmonary complications (63%) than in patients without pulmonary complications (31%) (P= 0.001), and this association was independent of age and clinical grade at admission (odds ratio, 3.68; P< 0.001). Overall clinical outcomes were worse in patients with pulmonary complications (mean Glasgow Outcome Scale score, 3.3) than in patients without pulmonary complications (mean Glasgow Outcome Scale score, 4.0; P= 0.0001), but pulmonary complications were not an independent predictor of worse outcome when adjusted for age and clinical grade at admission (odds ratio, 1.38; P= 0.315).

CONCLUSION

Patients who experience pulmonary complications after aneurysmal SAH have a higher incidence of symptomatic vasospasm than do patients without pulmonary complications. This most likely reflects both the failure to maintain aggressive hypervolemic and hyperdynamic therapy in patients with pulmonary compromise and the possible precipitation of congestive heart failure by hypervolemic therapy in patients with preexisting delayed ischemic neurological deficit. Although patients with pulmonary complications have worse overall clinical outcomes than do patients without pulmonary complications, this is attributable to older age and worse clinical grades at admission.

Deformation of the ventrolateral medulla oblongata by subarachnoid hemorrhage from ruptured vertebral artery aneurysms causes neurogenic pulmonary edema

The occurrence of neurogenic pulmonary edema (NPE) associated with subarachnoid hemorrhage (SAH) due to ruptured aneurysm was analyzed in 48 consecutive patients. Correlations of the location of the aneurysm, clinical grade, amount of subarachnoid clot, and severity of NPE were examined. NPE was observed in 29.4% of all SAH cases, but the incidence was significantly higher in cases of ruptured vertebral artery (VA) aneurysm. Clinical grade, severity of NPE, and deformation of the medulla oblongata were studied in the five cases of ruptured VA aneurysm. Deformation of the ventrolateral medulla oblongata was observed in all patients. Asymmetry index of the medulla oblongata measured on the axial computed tomography scan was correlated with the severity of NPE. Severity of NPE tended to correlate with deformation of the medulla oblongata. NPE associated with ruptured VA aneurysm is caused by deformation of the ventrolateral site of the medulla oblongata by the localized hemorrhage.

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.

Causes and outcome of mechanical ventilation in patients with hemispheric ischemic stroke

OBJECTIVE

To attempt to determine factors that influence outcome in mechanically ventilated patients with ischemic hemispheric stroke.

MATERIAL AND METHODS

We reviewed data on 24 mechanically ventilated patients with an ischemic stroke in the territory of the middle cerebral artery, who had been admitted to a medical, neurologic, or neurosurgical intensive-care unit during the period between 1976 and 1994.

RESULTS

The circumstances surrounding mechanical ventilation were generalized tonic-clonic seizures or status epilepticus (N = 6), progression to stupor and inability to protect the airway from brain swelling (N = 8), or--most commonly--bilateral pulmonary edema from congestive heart failure (N = 10). Of the 24 patients, 17 patients died (12 of neurologic causes and 5 of cardiac arrest or cardiac arrhythmias). Of the seven surviving patients, however, four with seizures and one with pulmonary edema were functionally independent.

CONCLUSION

Three clinical scenarios generally underlie mechanical ventilation in patients with ischemic hemispheric stroke (generalized tonic-clonic seizures, brain swelling, and bilateral pulmonary edema). The outcome in patients with an ischemic hemispheric stroke and a subsequent need for mechanical ventilation is poor; however, survival and independent function are possible if seizures or pulmonary edema prompt ventilatory support.

[Acute neurogenic pulmonary edema: a case report]

The authors report a case of acute neurogenic pulmonary edema in a 28-year-old woman who presented rupture of an internal carotid artery aneurysm and subarachnoid hemorrhage. The respiratory disorders started at the same time the patient's symptomatology aggravated. Some etiological and pathophysiological aspects on neurogenic pulmonary edema are revised.

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.

Respiratory distress associated with stereotactic irrigation of a brain cyst

Stereotactic neurosurgery is a procedure that usually requires monitored sedation or general anesthesia. The authors report a case in which stereotactic irrigation of a brain cyst was temporally associated with respiratory distress. Additionally, the stereotactic apparatus limits the anesthesiologist's access to the airway.