LAUSR

distress, followed by bradycardia and cardiac arrest. She was successfully revived and shifted to intensive care unit on ventilator support. In the intensive care unit the patient was hemodynamically stable. A 12-lead electrocardiogram showed sinus tachycardia with “T” wave inversion in leads I, V1-V2, and “ST” depression in leads V4-V6. TTE revealed LV global hypokinesia with reduced LV systolic function with an ejection fraction of 30%. Cardiac enzymes were mildly elevated (troponin I: 0.5 ng/mL). Her chest x-ray demonstrated bilateral pulmonary infiltrates suggesting NPE. Coronary angiogram revealed absence of coronary occlusive disease. Her clinical condition improved over the next few days. On day 5, a repeat TTE showed no regional wall motion abnormality with LV ejection fraction of 45%. On day 7, she underwent surgical excision of tumor with uneventful recovery. To the best of our knowledge, this is the first case report of NPE and NSM developing in an adult patient with a primary brain tumor. Sudden increase in intracranial pressure during hydrocephalic attacks leads to hypothalamic stimulation due to direct pressure or impaired hypothamaic venous drainage resulting in autonomic dysregulation. Subsequent excessive sympathetic stimulation increases norepinephrine level in the blood and causes myocardial dysfunction through (a) energy failure due to increased Ca load in cardiomyocytes, (b) coronary vasospasm and cardiac ischemia, (c) pulmonary vasoconstriction and increased pulmonary capillary pressure leading to pulmonary edema.3,4 Our hypothesis is described earlier with NPE resulting from colloid cyst of the third ventricle.5 However, in our case both NPE and NSM occurred as a consequence of acute sympathetic surge. We acknowledge that association of NPE and NSM with meningioma cannot be established based on a single case, but it should be suspected in presence of stress cardiomyopathy in patient with brain tumor and hydrocephalic attacks. Amit Goyal, MBBS, DNB Suparna Bharadwaj, MD, DM Department of Neuroanesthesia & Neurocritical care, National Institute of Mental Health and Neurosciences Bengaluru, Karnataka, India