Neurogenic Pulmonary Edema in Patients With Subarachnoid Hemorrhage

Abstract

Neurogenic pulmonary edema (NPE), leading to cardiopulmonary dysfunction, is a potentially life-threatening complication in patients with aneurysmal subarachnoid hemorrhage (SAH). We sought to assess the clinical presentation and risk factors for the development of NPE after SAH. The database contained prospectively collected information on 477 patients with SAH. Baseline characteristics, clinical and radiologic severity of the bleeding, localization of the ruptured aneurysm, and clinical outcome of patients with NPE were compared with those of patients without NPE. Further, in patients with NPE, intracranial pressure, serum cardiac biomarkers, and hemodynamic parameters during the acute phase were evaluated retrospectively. The incidence of NPE was 8% (39 of 477 patients). Most patients with NPE were severely impaired and all of them presented with radiologically severe hemorrhage. The incidence of NPE was significantly higher in patients with ruptured aneurysm in the posterior circulation. Elevated intracranial pressure was found in 67%, pathologically high cardiac biomarkers in up to 83% of patients with NPE. However, no patient suffered from persistent cardiac dysfunction. Compared with patients without NPE, patients with NPE showed poor neurologic outcome (Glasgow outcome scale 1 to 3 in 25% vs.77% of patients). In conclusion, patients with NPE have a high mortality rate more likely due to their severity grade of the bleeding. Morbidity and mortality due to cardiopulmonary failure might be reduced by appropriate recognition and treatment. The awareness of and knowledge about occurrence, clinical presentation, and treatment of NPE, are essential for all those potentially confronted with patients with SAH in the acute phase.

Subarachnoid Hemorrhage Complicated With Neurogenic Pulmonary Edema and Takotsubo-Like Cardiomyopathy

“…6,7) These findings may explain why poor-grade patients with ruptured posterior circulation aneurysm were significantly more likely to sustain NPE compared with anterior circulation aneurysm, as previously reported. 25,26) The results of this study, shown in Fig. 1B and Table 2, are compatible with the previous findings.…”

“…Ruptured posterior circulation aneurysms may also cause NPE more frequently compared with anterior circulation aneurysms. 25,26) In our institution, transthoracic ultrasonography is performed routinely in the emergency department for SAH patients presenting with the clinical/radiographic signs of NPE, allowing investigation of the incidence and demographics of SAH patients complicated with NPE-TCM.…”

“…Clinical criteria for NPE included the auscultation of crackles that suggested fluid in the lungs and presence of frothy pink tracheal fluid. 25) Radiographic criteria for NPE included sharp definition of pulmonary markings accompanied by blurring or haziness of the perivascular outlines and loss of demarcation of hilar shadows. 25) The radiographs were interpreted by board-certified specialists in emergency medicine, and patients who fulfilled both clinical and radiographic criteria were determined to have NPE.…”

“…3,9,19,25) The association of NPE with poorgrade SAH has been known for years. 9,25,29,34,35) The reported incidence of NPE in SAH patients ranges from 2% to 29%. 9,25) TCM, also known as stunned myocardium, 19) has been associated etiologically with SAH.…”

“…9,25,29,34,35) The reported incidence of NPE in SAH patients ranges from 2% to 29%. 9,25) TCM, also known as stunned myocardium, 19) has been associated etiologically with SAH. 3,18,19,27) The reported incidence of TCM in SAH patients ranges from 4% to 15%.…”