An Uncommon and Lethal Scenario: Neurogenic Pulmonary Edema, Impaired Left Ventricular Function, and Resistant Ventricular Fibrillation Following Grade 3 Subarachnoid Hemorrhage - a Unique Case Report.

Abstract

Background: Neurogenic pulmonary edema (NPE) is a rare but serious complication of acute brain injuries, including subarachnoid hemorrhage (SAH). The early recognition and management of NPE in the context of SAH are crucial for improving patient outcomes. This case report discusses a fatal presentation of SAH complicated by acute NPE, cardiovascular compromise, and fatal arrhythmia. Case Presentation: A previously healthy 40-year-old woman was urgently transferred to the Emergency Treatment Unit at Anuradhapura Teaching Hospital after experiencing sudden loss of consciousness, generalized seizures, and severe respiratory distress. Initial assessment revealed a blocked airway due to frothy secretions, labored breathing with low oxygen saturation, and hemodynamic instability. Neurological examination indicated a Glasgow Coma Scale score of 7. Point-of-care ultrasound (POCUS) and imaging studies confirmed pulmonary edema, reduced cardiac ejection fraction, and a Grade IV subarachnoid hemorrhage according to the Fisher scale. Despite aggressive medical interventions, including intubation, ventilation, and inotropic support, the patient’s condition deteriorated, leading to ventricular fibrillation and, ultimately, her demise. Discussion: The case highlights the importance of early identification and prompt management of NPE in patients with SAH. The pathophysiology of NPE involves complex interactions between neurogenic, hemodynamic, and inflammatory factors, which can lead to rapid clinical decline. ECG changes, such as widespread ST-segment depression, may serve as early indicators of acute pulmonary complications in SAH patients. Multidisciplinary collaboration, standardized treatment protocols, and continuous quality improvement initiatives are recommended to enhance the management of similar cases. Conclusion: This case underscores the critical need for heightened awareness and early intervention in the management of NPE associated with SAH. Timely, coordinated care may improve outcomes and reduce mortality in patients with this challenging clinical presentation.