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Critical Care  2010 

Wet lungs, broken hearts and difficult therapies after subarachnoid hemorrhage

DOI: 10.1186/cc8936

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An acute catecholamine discharge immediately following intracranial bleeding can have devastating extracranial effects: the heart, lungs, fluids and electrolytes can be severely affected. Hoff and colleagues report on pulmonary edema (PE) following subarachnoid hemorrhage (SAH) [1]. They found a high incidence of PE, usually several days after the initial bleeding, and an association of PE with lower intra vascular volumes (compared with cases without PE). PE is not uncommon after SAH, both as an early complication and as a late complication.Neurogenic PE is an acute event directly linked with an intracranial disaster; as such, it is often diagnosed on admission in cases with severe SAH [2]. PE in the days following SAH has been reported in association with triple-H therapy, which includes hypervolemia and induced arterial hypertension [3]. In different series, the PE incidence varied from 14 to 23% [4,5]. Increasing evidence is accumulating on the myocardial dysfunction that follows SAH, as well as other acute intracranial disasters. Takotsubo syndrome - with typical left ventricular abnormalities (bulging out of the apex of the heart with preserved function of the base, which earned the syndrome its name - a kind of a pot used as octopus trap in Japan), ECG abnormalities and biomarker changes - is a typical example of how much an injured brain can break the heart [6]. Neurogenic in origin, left ventricular failure causes congestion in the pulmonary vasculature and PE in Takotsubo syndrome.What is concerning in the report of Hoff and colleagues is that PE, often labeled in the text as neurogenic PE, has been diagnosed days after the initial bleeding, without concurrent reduction of the cardiac index and in the absence of volume expansion [1]. The clinical implications of these findings, as pointed out by the authors, would be that PE more than 4 days after SAH is not cardiogenic and would not be suitable for treatment with diuretics. It is therefore hard to reconci


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