Intraventricular colloid cyst, hydrocephalus and neurogenic stunned myocardium

Acute Obstructive Hydrocephalus: An Unexpected Cause of Cardiac Arrest

BACKGROUND

Emergency physicians are well-versed in managing cardiac arrests, including the diagnostic and therapeutic steps after return of spontaneous circulation. Neurologic emergencies are a common cause of out-of-hospital cardiac arrest and must remain high in the differential diagnosis, as such cases often require specific interventions that may deviate from more common care pathways. Performing a noncontrast head computed tomography (NCHCT) scan after cardiac arrest has been found to change management, although the optimal timing of this imaging is unclear.

CASE REPORT

This is the case of a young, pregnant woman who presented to the emergency department after cardiac arrest with return of spontaneous circulation in the prehospital setting. She was found to have acute obstructive hydrocephalus on NCHCT, which was later confirmed to be due to a previously undiagnosed colloid cyst of the third ventricle. This acute obstruction resulted in myocardial stunning and, ultimately, cardiac arrest. Although outcomes are often dismal when the cause of arrest is secondary to neurologic catastrophe, this patient survived with completely intact neurologic function. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although acute obstructive hydrocephalus due to a colloid cyst adjacent to the third ventricle is a rare condition, it is a potentially reversible neurologic cause of out-of-hospital cardiac arrest. However, positive outcomes depend on obtaining the diagnosis rapidly with neurologic imaging and advocating for neurosurgical intervention. This case supports the recommendation that emergency physicians should strongly consider post-cardiac arrest neurologic imaging when another cause is not immediately obvious.

Diagnostic Methods in Forensic Pathology: Autoptic Findings and Immunohistochemical Study in Cases of Sudden Death Due to a Colloid Cyst of the Third Ventricle

The colloid cyst is a non-malignant tumor growth made of a gelatinous material covered by a membrane of epithelial tissue. It is usually located posterior to the foramen of Monro, in the anterior aspect of the third ventricle of the brain. Due to its location, it can cause obstructive hydrocephalus, increased intracranial pressure, and sudden cardiac death, catecholamine-mediated, through hypothalamus compression. All the mechanisms are still controversial, but the role of catecholamine has been confirmed with histological findings that highlighted myocardial injury (coagulative myocytolysis and contraction band necrosis, CBN). This study presents a case of sudden death in a previously healthy 22-year-old male due to a colloid cyst of the third ventricle. A complete autopsy was performed, highlighting in the brain an abundant quantity of cerebrospinal fluid (CSF) and a 2 cm pale grayish-green rounded cyst formation partially filling and distending the third ventricle. The diagnosis was confirmed through immunohistochemical investigation: positivity for Periodic acid-Schiff (PAS) staining and CK7 expression. In cases such as the one reported here, a combined approach of autopsy, histology, and immunohistochemistry is mandatory in order to identify the neoformation's location and morpho-structural characteristics for a correct differential diagnosis, as well as to identify the cause of death.

Giant Colloid Cyst

Giant colloid cysts are defined as cysts of more than 3 cm in maximal diameter. Few cases of giant colloid cysts have been reported in the literature. We herein describe a giant colloid cyst. A 15-year-old female presented with headache, blurred vision, and episodic behavioral changes for three months. Neurological examination was limited due to agitation and confusion. Fundoscopy was notable for bilateral papilledema. Brain CT revealed a giant third-ventricular lesion, causing obstructive hydrocephalus. The patient underwent urgent ventriculoperitoneal shunt insertion initially and then cyst excision. The histopathological sections of the lesion were compatible with a colloid cyst. Five years following surgical resection, a brain MRI did not demonstrate any evidence of residual or cyst recurrence. To our knowledge, giant colloid cysts have been rarely reported and pose a management dilemma in the literature. The present article highlights the symptomatology, radiological findings, and outcome of a giant colloid cyst.

Pediatric takotsubo syndrome caused by hydrocephalus after posterior fossa tumor surgery

Takotsubo syndrome (TTS) can develop after intense physical or emotional stress and is uncommon in children. We report a 2-year-old girl who developed TTS caused by acute hydrocephalus after posterior fossa tumor resection and required mechanical ventilation and administration of vasopressor/inotropic agents. Her cardiac function gradually recovered over the course of 2 weeks. Hydrocephalus after posterior fossa surgery can cause compression of the medulla oblongata, resulting in solitary nucleus dysfunction and TTS, a potentially life-threatening complication.

A 3rd ventricular colloid cyst causing acute hydrocephalus with stunned myocardium: A case report

Background: Third ventricular colloid cysts are benign but may cause acute hydrocephalus, raised intracranial pressure, decreased consciousness level, and sudden death. These ventricular colloid cysts associated with stunned myocardium are rarely reported in the literature. This study reported a case of a third ventricular colloid cyst presented as acute hydrocephalus complicated with severe neurogenic pulmonary edema, stunned myocardium, and heart failure, which survived at the end.

Case presentation: A 29-year-old woman presented to the emergency department with one day history of headache, vomiting, and altered consciousness level. Early brain imaging showed a cyst in the third ventricle. The patient rapidly deteriorated neurologically and developed severe pulmonary edema and heart failure requiring immediate external ventricular drain and heart failure management. Once stabilized, she underwent endoscopic excision of the ventricular cyst. Histopathology confirmed the diagnosis of colloidal cyst. She survived all these acute life-threatening events, improved, and stabilized, and was discharged home. She was followed up in outpatient clinics after 6 months of discharge with no symptoms or neurological deficit.

Conclusion: A third ventricular colloid cyst can cause acute hydrocephalus leading to stunned myocardium requiring immediate surgical intervention, advanced hemodynamic monitoring, and acute heart failure management.

Hydrocephalus-induced neurogenic stunned myocardium and cardiac arrest in a child: completely reversed with CSF diversion

Neurogenic stunned myocardium (NSM) is a potentially fatal cause of sudden cardiogenic dysfunction due to an acute neurological event, most commonly aneurysmal subarachnoid hemorrhage in adults. Only two pediatric cases of hydrocephalus-induced NSM have been reported. Here the authors report a third case in a 14-year-old boy who presented with severe headache, decreased level of consciousness, and shock in the context of acute hydrocephalus secondary to fourth ventricular outlet obstruction 3 years after standard-risk medulloblastoma treatment. He was initially stabilized with the insertion of an external ventricular drain and vasopressor treatment. He had a profoundly reduced cardiac contractility and became asystolic for 1 minute, requiring cardiopulmonary resuscitation when vasopressors were inadvertently discontinued. Over 1 week, his ventricles decreased in size and his cardiac function returned to normal. All other causes of heart failure were ruled out, and his impressive response to CSF diversion clarified the diagnosis of NSM secondary to hydrocephalus. He was unable to be weaned from his drain during his time in the hospital, so he underwent an endoscopic third ventriculostomy and has remained well with normal cardiac function at more than 6 months' follow-up. This case highlights the importance of prompt CSF diversion and cardiac support for acute hydrocephalus presenting with heart failure in the pediatric population.

Takotsubo cardiomyopathy in the setting of acute hydrocephalus secondary to neurocysticercosis

We report the case of a 45-year-old male who presented with transient neurogenic stunned myocardium, or takotsubo cardiomyopathy, secondary to acute hydrocephalus caused by obstruction of the third ventricle by neurocysticercosis.

Neurosurgical management of a giant colloid cyst with atypical clinical and radiological presentation

The finding of a colloid cyst on neuroimaging is often incidental. These lesions are usually located at the foramen of Monro, are hyperdense on CT scans, and generally demonstrate signal intensity of water on MR images, although this depends on their content. When symptomatic, they frequently present with headaches and nausea due to an obstructive hydrocephalus. The authors describe a case of a giant colloid cyst in a patient presenting with complete left-sided vision loss and progressive memory loss, two very atypical findings in colloid cyst presentation. Imaging findings were also atypical, and this case proved to be a diagnostic dilemma because of its clinical and radiological presentation. Histopathological investigation was of utmost importance in the final diagnosis of a colloid cyst. To the authors' knowledge this colloid cyst is larger than any other described in the literature.

Colloid cyst of the third ventricle, hypothalamus, and heart: a dangerous link for sudden death

Colloid cysts are rare congenital, intracranial neoplasms, commonly located in the third ventricle. Colloid cysts are endodermal congenital malformations. The cysts commonly range in size from 1-2 cm in diameter, although large cysts >3 cm in size have been reported. The components of the cyst include an outer fibrous capsule over an inner epithelium. The epithelium is usually a single layer of mucin-producing or ciliated cells. Such cysts contain mucoid and gelatinous material, which is positive for both Periodic acid Schiff (PAS) and mucicarmen staining. Although colloid cysts usually represent histopathologically benign neoplasms, they can result in sudden, unexpected and potentially lethal complications. The mechanism(s) of death is still a controversial subject and several mechanisms have been postulated to explain the sudden onset of severe symptoms and of fatal rapid deterioration in patients with colloid cysts. In this case, macroscopic and histological findings addressed the diagnosis of colloid cyst of the third ventricle with diffuse myocardial injury (coagulative myocytolysis or contraction band necrosis, CBN) and led us to conclude that acute cardiac arrest due to hypothalamus stimulation in the context of colloid cyst of the third ventricle was the cause of death. As the hypothalamic structures which are involved in neuroendocrine and autonomic regulation playing a key role in cardiovascular control are located close to the walls of the third ventricle which is the most frequent anatomical site of colloid cyst, this may suggest that reflex cardiac effects due to the compression of the hypothalamic cardiovascular regulatory centers by the cyst explain the sudden death in patients harboring a colloid cyst when signs of hydrocephalus or brain herniation are lacking.

VIRTUAL SLIDES

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/4915842848034158.

Neurogenic stunned myocardium presenting as left ventricular hypertrabeculation in childhood: a variant of Takotsubo cardiomyopathy?

OBJECTIVE

To report the first case of neurogenic stunned myocardium presenting with heart left ventricle noncompaction requiring intensive care in the perioperative period of tension tumor-induced hydrocephalus.

METHODS AND DESIGN

Case report and literature review. Our Institutional Review Board waived the need for consent.

PATIENT

A 12-yr-old female with intracranial astrocytoma and hypertensive hydrocephalus presented with severe heart dysfunction and life-threatening ventricular ectopies intraoperatively. A severe heart failure developed requiring hemodynamic and ventilatory support for 10 days. Echocardiography showed a transient noncompaction aspect of the left ventricular wall, further confirmed by a cardiac magnetic resonance image. The noncompaction aspect lasted until 15 days postadmission, as was the case for the QT interval prolongation; no life-threatening ectopies were demonstrated on the subsequent Holter electrocardiogram monitoring.

CONCLUSIONS

This report describes a unique presentation of myocardial stunning in association with an intracranial illness, namely, a hypertensive hydrocephalus complicating an intracranial neoplasm.

Acute myelitis with neurogenic stunned myocardium in a boy

Neurogenic stunned myocardium is characterized by reversible left ventricular dysfunction, which occurs after severe central nervous system injury in patients without coronary artery disease. It has been described in association with subarachnoid hemorrhage, Guillain-Barré syndrome, and metastatic brain tumors in adults, but has been rarely reported in association with acute myelitis. Described here is a novel case of acute myelitis in a child associated with neurogenic stunned myocardium. This case demonstrates that patients with acute myelitis may harbor a risk of sympathetic dysregulation, leading to neurogenic myocardial dysfunction.

Neurogenic stunned myocardium after acute hydrocephalus

Neurogenic stunned myocardium (NSM) is a syndrome of cardiac stunning after a neurological insult. It is commonly observed after aneurysmal subarachnoid hemorrhage but is increasingly being reported after other neurological events. The underlying mechanism of NSM is believed to be a hypothalamic-mediated sympathetic surge causing weakened cardiac contractility and even direct cardiac myocyte damage. The authors report 2 cases of NSM in pediatric patients after acute hydrocephalus. Both patients experienced severe cardiac dysfunction in the acute phase but ultimately had a good neurological outcome and a full cardiac recovery. The identification, treatment, and outcome in 2 rare pediatric cases of NSM are discussed, and the history of the brain-cardiac connection is reviewed.

Chronic hydrocephalus and alcohol abuse in a young male suicide

The paper describes a case of suicide in a young man affected by compensated chronic hydrocephalus who was subject to alcohol abuse. The case was studied by means of a complex set of analyses, including circumstantial and clinical data, anatomohistopathological findings, and chemicotoxicologic tests. What clearly emerges in the case is the importance of a continuing neuropsychological follow-up in patients with shunted hydrocephalus. The forensic interest in the case is due to the peculiar autopsy findings discussed in relation to the possible causes of sudden death in subjects with hydrocephalus.

Neurogenic stunned myocardium: an unusual postoperative complication

OBJECTIVE

In this report of myocardial dysfunction in a pediatric patient after a neurosurgical procedure, we highlight the need for high clinical suspicion for neurogenic stunned myocardium.

DESIGN

Case report.

SETTING

A tertiary pediatric intensive care unit.

PATIENT

A 7-yr-old boy with a history of Chiari malformation type 1, undergoing his fourth surgical procedure, who developed signs of myocardial infarction in the immediate postoperative period.

INTERVENTIONS

Serial echocardiograms, a rest-stress myocardial perfusion study, and coronary angiography were performed. Serial troponins were followed.

RESULTS

The troponin level normalized 6 days after the initial event, and he was discharged home on a limited course of lisinopril, propanolol, and aspirin and without signs or symptoms of cardiac dysfunction.

CONCLUSIONS

Neurogenic stunned myocardium is an uncommon event after neurosurgical procedures in children. Pediatric intensivists need to consider this diagnosis in a patient with signs of myocardial dysfunction in the neurosurgical postoperative period. The management of neurogenic stunned myocardium involves close monitoring and establishing the absence of other causes of myocardial ischemia.

Neurogenic stunned myocardium and transient severe tricuspid regurgitation in a child following nonaccidental head trauma

Neurogenic stunned myocardium is widely reported in the adult literature and is typically associated with subarachnoid hemorrhage. We present a case of neurogenic stunned myocardium and transient severe tricuspid regurgitation in a 7-month-old infant following nonaccidental head trauma.