Pediatric Neurogenic Pulmonary Edema After Brain Tumor Removal Complicated with Severe Myocardial Injury: A Case Report

Abstract

BACKGROUND Neurogenic pulmonary edema (NPE) is a rare complication of neurological insults, such as traumatic brain injury and intracranial hemorrhage, in children. NPE frequently accompanies left ventricular (LV) dysfunction mediated via central catecholamine surge and inflammation. A high serum natriuretic (BNP) level was prolonged even after the LV contraction was improved in this case with severe myocardial injury. The overloading stress to the LV wall can last several days over the acute phase of NPE. CASE REPORT A 6-year-old boy developed NPE after the removal of a brain tumor in the cerebellar vermis, which was complicated by hydrocephalus. Simultaneously, he experienced LV dysfunction involving reduced global contraction with severe myocardial injury diagnosed by abnormally elevated cardiac troponin I level (1611.6 pg/ml) combined with a high serum BNP level (2106 pg/ml). He received mechanical ventilation for 4 days until the improvement of his pulmonary edema in the Intensive Care Unit (ICU). On the next day, after the withdrawal of mechanical ventilation, he was discharged from the ICU to the pediatric unit. Although the LV contraction was restored to an almost normal range in the early period, it took a total of 16 days for the serum BNP level to reach an approximate standard range (36.9 pg/ml). CONCLUSIONS Even in a pediatric patient with NPE, we recommend careful monitoring of the variation of cardiac biomarkers such as BNP until confirmation of return to an approximate normal value because of the possible sustained overloading stress to the LV wall.

Figure 1.

Preoperative brain computed tomography image showing a brain tumor (∇) in the cerebellar vermis, complicated with lateral and third-ventricle enlargement.

Figure 2.

Chest computed tomography images showing wide-spread consolidation, mostly located in the dorsal regions of the bilateral lung fields and suggesting severe pulmonary edema.

Figure 3.

Time course of serum levels of high-sensitivity cardiac troponin I (hs-cTn I) and brain natriuretic peptide (BNP) after readmission to the Intensive Care Unit (ICU); the vertical bar represents the serum levels (pg/mL) of cTn I and BNP. The horizontal bar represents the day after readmission to the ICU.□--□ and ○--○ denote the serial changes in serum levels of BNP and cTn I, respectively. The standard upper limits of hs-cTn I and BNP levels are 26.2 pg/mL and 18.4 pg/mL, respectively.