Nucleus tractus solitarius lesions elevate pulmonary arterial pressure and lymph flow

Role of autonomic system imbalance in neurogenic pulmonary oedema

Neurogenic pulmonary oedema (NPE) is a life-threatening complication that develops rapidly and dramatically after an injury to the central nervous system (CNS). The autonomic system imbalance produced by severe brain damage may play an important role in the development of NPE. Activation of the sympathetic nervous system and inhibition of the vagus nerve system are essential prerequisites for autonomic system imbalance. The more severe the damage, the more pronounced the phenomenon. Sympathetic hyperactivity is associated with increased release of catecholamines from peripheral sympathetic nerve endings, which can cause dramatic changes in haemodynamics and cause pulmonary oedema. On the other hand, the abnormal inflammatory response caused by vagus nerve inhibition may also play an important role in the pathogenesis of NPE. The perspective of autonomic system imbalance seems to perfectly integrate the existing pathogenesis of NPE and can explain the entire development progression of NPE.

Pulmonary Complications After Spontaneous Aneurysmal Subarachnoid Hemorrhage: Experience from Barrow Neurological Institute

OBJECTIVE

Because the clinical course of spontaneous aneurysmal subarachnoid hemorrhage (aSAH) can be compromised by pulmonary complications, we sought to review posttreatment outcomes in aSAH patients with and without pulmonary complications.

METHODS

Patient demographic, clinical, and outcome data (March 2003-January 2007) were analyzed retrospectively. Patients underwent microsurgical or endovascular treatment for aSAH; pulmonary complications were reported. Outcomes were assessed using the Glasgow Outcome Scale (GOS) scores at the 1-year, 3-year, and 6-year follow-up visits.

RESULTS

The cohort comprised 471 patients (mean age, 53.7 ± 12.4 years; men, 332/471 [70%]). The mean Glasgow Coma Scale (GCS) score at presentation was 11.9 ± 3.0. Of 471 patients, 47% (n = 223) presented with a Hunt and Hess score of ≥3 and 76% (n = 357) with a Fisher grade of 3. Treatment was clipping for 69% (279/407) and coiling for 31% (128/407) of patients. Pulmonary complications occurred in 210 of 471 (45%) patients. Nearly one-half of patients were discharged to home (215/471, 46%), and more than one-half had a good outcome defined as a GOS score of 5 at their 1-year (226/403, 56%), 3-year (217/397, 55%), and 6-year (203/380, 53%) follow-up visits. Logistic regression showed age and GCS scores as outcome predictors at all time points, whereas pulmonary complications predicted poor outcome only at the 1-year follow-up visit.

CONCLUSIONS

Pulmonary problems represent the most common nonneurologic medical complications after aSAH. Despite advances in critical care, pulmonary complications represented predictors of short-term poor outcome only at the 1-year follow-up visit, whereas the medical history of the patient became more relevant for prognosis in long-term follow-up.

Elevated cerebrospinal fluid endothelin 1 associated with neurogenic pulmonary edema in children with enterovirus 71 encephalitis

OBJECTIVES

Neurogenic pulmonary edema (NPE) is a fatal complication in children with enterovirus 71 (EV71) encephalitis. Endothelin 1 (ET-1), a potent vasoconstrictor, can induce pulmonary edema in rats via intrathecal injections. Thus, it was hypothesized that ET-1 in the central nervous system may correlate with NPE in children with EV71 encephalitis.

METHODS

Clinical data and ET-1 in the cerebrospinal fluid (CSF) were compared between three groups: (1) EV71 encephalitis with NPE; (2) EV71 encephalitis without NPE; and (3) non-EV71 aseptic meningitis. ET-1 immunostaining was performed on the brainstem of autopsy patients.

RESULTS

The EV71 with NPE group showed significantly increased CSF levels of ET-1 compared to the EV71 without NPE and the non-EV71 aseptic meningitis groups (both p<0.01). The optimum cut-off point of ET-1 to predict NPE in EV71 patients, based on the receiver operating characteristic curve, was 0.5 pg/ml (sensitivity 83%, specificity 100%). Immunostaining in the brainstem showed increased ET-1 expression, mainly in the oligodendrocytes, in EV71 with NPE patients compared with control patients.

CONCLUSION

ET-1 in the central nervous system may play a role in the development of NPE in children with EV71 infection and could be used as a biomarker or therapeutic target for NPE in EV71 encephalitis.

Neurogenic pulmonary edema and acute respiratory distress syndrome in a healthy child with febrile status epilepticus

Neurogenic pulmonary edema is a clinical syndrome that manifests as an acute onset of pulmonary edema in the setting of a central nervous system injury, without cardiac dysfunction. Neurogenic pulmonary edema is rare in children, and the mechanism is still not completely understood.  The clinical pathology overlaps with acute lung injury and acute respiratory distress syndrome. The authors report a case of a 14-month-old previously healthy child who presented with febrile status epilepticus, fulminant neurogenic pulmonary edema, and acute respiratory distress syndrome.  Neurogenic pulmonary edema should be considered in the differential diagnosis for the rapid progression of respiratory failure following an acute neurological injury such as status epilepticus in a child. Prompt respiratory support and treatment of the acute neurological insult can prevent further cerebral hypoxemic injury.

Strategies for the use of mechanical ventilation in the neurologic intensive care unit

Mechanical ventilation in neurologically injured patients presents unique challenges. Patients with acute neurologic injuries may require mechanical ventilation for reasons beyond respiratory failure. There is also a subset of pulmonary pathologic abnormality directly associated with neurologic injuries. Balancing the need to maintain brain oxygenation, cerebral perfusion, and control of intracranial pressure can be in conflict with concurrent ventilator strategies aimed at lung protection. Weaning and liberation from mechanical ventilation also require special considerations. These issues are examined in the ventilator management of the neurologically injured patient.

Neurogenic pulmonary edema

Neurogenic pulmonary edema (NPE) is usually defined as an acute pulmonary edema occurring shortly after a central neurologic insult. It has been reported regularly for a long time in numerous and various injuries of the central nervous system in both adults and children, but remains poorly understood because of the complexity of its pathophysiologic mechanisms involving hemodynamic and inflammatory aspects. NPE seems to be under-diagnosed in acute neurologic injuries, partly because the prevention and detection of non-neurologic complications of acute cerebral insults are not at the forefront of the strategy of physicians. The presence of NPE should be high on the list of diagnoses when patients with central neurologic injury suddenly become dyspneic or present with a decreased P(a)o(2)/F(i)o(2) ratio. The associated mortality rate is high, but recovery is usually rapid with early and appropriate management. The treatment of NPE should aim to meet the oxygenation needs without impairing cerebral hemodynamics, to avoid pulmonary worsening and to treat possible associated myocardial dysfunction. During brain death, NPE may worsen myocardial dysfunction, preventing heart harvesting.

[Unilateral neurogenic pulmonary edema. A case report]

A vascular lesion was identified in the posterior cerebral fossa in a 65-Year-old stroke victim. The patient suddenly developed unilateral pulmonary edema. Bilateral alveolar opacities is the usual radiological aspect of neurogenic pulmonary edema but a unilateral presentation is extremely rare. The differential diagnosis includes excessive vascular filling, infectious pneumonia, gastric fluid aspiration edema, and cardiogenic pulmonary edema. The mechanisms underlying neurogenic pulmonary edema are discussed.

Neurogenic pulmonary edema in enterovirus 71 encephalitis is not uniformly fatal but causes severe morbidity in survivors

During the Australian summer of 2000/2001, there was an outbreak of enterovirus 71 infection in Sydney. Between December 2000 and May 2001, approximately 200 children presented to Sydney Children's Hospital with hand-foot-and-mouth disease and 18 experienced neurologic complications. Four presented with acute invasive central nervous system disease and severe pulmonary edema. We describe the cardiorespiratory disturbances and intensive care management of these four consecutive children successfully treated for neurogenic pulmonary edema attributed to proven enterovirus 71 infection. All four survived the acute stage of the illness. However, all four have been left with significant debilitating morbidity. Epidemic enterovirus 71 brainstem encephalitis presenting as neurogenic pulmonary edema can be successfully managed in the pediatric intensive care unit but has great potential to yield a large number of handicapped toddlers and become "the poliomyelitis of the 21st century."

Pulmonary transplantation: the role of brain death in donor lung injury

The paucity of suitable lung donors and the high early mortality as the result of primary graft failure remain major challenges in pulmonary transplantation. There is evidence that the lung is injured in the donor by the process of brain death and often is made unusable or fails posttransplantation after amplification of the injury by the process of ischemia-reperfusion. An understanding of the mechanism of donor lung injury could lead to the development of new treatment strategies for the donor to reduce lung injury, increase the number of donors with acceptable lungs, and improve the results of transplantation. The pathophysiology of brain death is complex and involves sympathetic, hemodynamic, and inflammatory mechanisms that can injure the lung. The literature is reviewed, and these mechanisms are discussed together with their possible interrelations.

Acute pulmonary oedema: presenting symptom of multiple sclerosis

Acute pulmonary oedema and headache are both common. The former is usually cardiogenic in origin. Severe headache of sudden onset in a young person may be suggestive of subarachnoid headache. We describe a 24-year-old man who presented with headache and pulmonary oedema, finally ascribed to multiple sclerosis. This is the first report of neurogenic pulmonary oedema as the first symptom of multiple sclerosis. We review the neuroanatomical basis and experimental evidence for neurogenic pulmonary oedema.

Neurogenic pulmonary edema induced by primary medullary hemorrhage: a case report

We report a case of neurogenic pulmonary edema occurring in association with primary medullary hemorrhage. A pervious healthy 28-year-old man suddenly developed severe dyspnea without cardiac failure. Radiographs and computed tomography of the chest showed pulmonary edema. A diagnosis of primary medullary hemorrhage was made some weeks later by cranial magnetic resonance imaging showing an area of low signal intensity in both T1- and T2-weighted images in the right ventrolateral, medial, and dorsal medulla, extending from low to mid levels. We suspect that edema surrounding the lesion had superimposed an element of left dorsal medullary dysfunction and that bilateral dorsal medullary involvement had induced neurogenic pulmonary edema.

Respiratory failure without pulmonary edema following injection of a glutamate agonist into the ventral medullary raphe of the rat

Injection of ibotenic acid (IA), a glutamate agonist, into the ventral medullary raphe (VMR; especially the nucleus raphe magnus) of the rat produced respiratory failure and death following a predictable course of events. The response to the IA injection was characterized initially by increased respiratory frequency and was followed by pulmonary arterial hypertension, systemic arterial hypoxemia, acidosis, and hypothermia. Within 90 min apnea occurred as a terminal event in all animals. Gravimetric, bronchoalveolar lavage protein, and histological analyses revealed no evidence of pulmonary edema. Intracerebral (VMR) pretreatment with PPP, a sigma receptor agonist, or scopolamine, a muscarinic cholinergic antagonist, prevented pulmonary failure and death even though postmortem histological analysis showed VMR cell loss and gliosis consequent to the cytotoxic IA injection. Based on the results of the study, it is suggested that the VMR has a role in regulation of pulmonary blood flow. Preliminary pharmacological studies suggested that a disruption of glutamatergic and cholinergic mechanisms mediates the lethal pulmonary phenomenon.

Medullary lesion inducing pulmonary edema: a magnetic resonance imaging study

A 27-year-old woman with a recent diagnosis of multiple sclerosis developed several episodes of noncardiogenic pulmonary edema over a 3-month period, each requiring intubation and ventilatory support. The development and subsequent resolution of an isolated lesion at the obex was correlated with the episodes. The literature regarding the anatomical basis of neurogenic pulmonary edema is reviewed.

[The nucleus tractus solitarius: neuroanatomic, neurochemical and functional aspects]

The nucleus tractus solitarii (NTS) has long been considered as the first central relay for gustatory and visceral afferent informations only. However, data obtained during the past ten years, with neuroanatomical, biochemical and electrophysiological techniques, clearly demonstrate that the NTS is a structure with a high degree of complexity, which plays, at the medullary level, a key role in several integrative processes. The NTS, located in the dorsomedial medulla, is a structure of small size containing a limited number of neurons scattered in a more or less dense fibrillar plexus. The distribution and the organization of both the cells and the fibrillar network are not homogeneous within the nucleus and the NTS has been divided cytoarchitectonically into various subnuclei, which are partly correlated with the areas of projection of peripheral afferent endings. At the ultrastructural level, the NTS shows several complex synaptic arrangements in form of glomeruli. These arrangements provide morphological substrates for complex mechanisms of intercellular communication within the NTS. The NTS is not only the site of vagal and glossopharyngeal afferent projections, it receives also endings from facial and trigeminal nerves as well as from some renal afferents. Gustatory and somatic afferents from the oropharyngeal region project with a crude somatotopy within the rostral part of the NTS and visceral afferents from cardiovascular, digestive, respiratory and renal systems terminate viscero-topically within its caudal part. Moreover the NTS is extensively connected with several central structures. It projects directly to multiple brain regions by means of short connections to bulbo-ponto-mesencephalic structures (parabrachial nucleus, motor nuclei of several cranial nerves, ventro-lateral reticular formation, raphe nuclei...) and long connections to the spinal cord and diencephalic and telencephalic structures, in particular the hypothalamus and some limbic structures. The NTS is also the recipient of several central afferent inputs. It is worth to note that most of the structures that receive a direct projection from the NTS project back to the nucleus. Direct projections from the cerebral cortex to the NTS have also been identified. These extensive connections indicate that the NTS is a key structure for autonomic and neuroendocrine functions as well as for integration of somatic and autonomic responses in certain behaviors. The NTS contains a great diversity of neuroactive substances. Indeed, most of the substances identified within the central nervous system have also been detected in the NTS and may act, at this level, as classical transmitters and/or neuromodulators.(ABSTRACT TRUNCATED AT 400 WORDS)

Medulla oblongata edema associated with neurogenic pulmonary edema. Case report

Neurogenic pulmonary edema (NPE) occurs in association with central nervous system disease without underlying cardiopulmonary problems. It is characterized by profound pulmonary vascular congestion and a fulminant clinical course. Although several reports document a role for experimental brain-stem lesions in the production of NPE, there have been only two studies in man correlating specific brain-stem lesions with NPE. The authors report a case of NPE occurring in a patient with von Hippel-Lindau disease and a dorsal medullary syrinx with postoperative dorsal medullary edema. The anatomical location of this patient's lesion is reviewed in the context of alternative theories of the pathogenesis of NPE.