Neurogenic pulmonary edema and Takotsubo cardiomyopathy in aneurysmal subarachnoid hemorrhage

Objective: Neurogenic pulmonary edema (NPE) combined with Takotsubo cardiomyopathy (TCM) is a unique condition associated with aneurysmal subarachnoid hemorrhage (aSAH). Although several mechanisms have been proposed, the pathophysiology and management strategies are not yet fully established. We aimed to determine the radiological and clinical outcome of patients with NPE with TCM after aSAH and to propose management strategies. Methods: We analyzed the data of 573 patients with aSAH recorded at a single medical center from February 2015 to July 2022. This study retrospectively investigated the incidence and demographics of SAH combined with both NPE and TCM and the clinical outcomes of the patients. Risk factors of NPE-TCM were also investigated. Results: During the 7 years, 11 (1.9%) of 513 patients had NPE complicated with TCM after aSAH. All 11 patients had poor-grade SAH (Hunt–Hess Grade 3 to 5). Three of 11 patients had posterior circulation in the NPE-TCM group. The most prevalent treatment option was endovascular coil embolization except for one case of clip. Long-term outcomes were favorable in 6 of 11 patients, and there was one case of mortality. Age, troponin I level, and alveolar-arterial oxygen gradient were risk factors of NPE-TCM. Conclusion: NPE combined with TCM is a unique finding in patients with aSAH, and severe clinical conditions may be independent predictors of a fatal outcome. Therefore, understanding the pathophysiology and appropriate management of this condition can improve outcome in patients with aSAH.