title: Ruptured spinal arteriovenous malformation: Presenting as stunned myocardium and neurogenic shock.
abstract: BACKGROUND
  Neurogenic pulmonary edema (NPE) is a clinical syndrome usually defined as an acute pulmonary edema occurring shortly after a central neurologic insult. NPE was identified 100 years ago, but it is still underappreciated in the clinical setup. NPE usually appears within minutes to hours after the injury. It has a high mortality rate if not recognized early and treated appropriately. Similarly, neurogenic shock is a known complication of spinal cord injury reported incidence is more than 20% in isolated upper cervical spinal injury. But NPE is rare to occur, and stunned myocardium (SM) is not reported in spinal arteriovenous malformation (AVM) rupture. SM is a reversible cardiomyopathy resulting in transient left ventricular dysfunction which has been described to occur in the setting of catecholamine release during situations of physiologic stress. We report a case of high spinal AVM rupture presenting as SM, NPE, and neurogenic shock.
  
  
  METHODS
  A 32-year-old male who presented with sudden onset of pain and weakness in upper limbs. Imaging studies showed AVM rupture by imaging techniques. Initially, the patient had severe hypertension, respiratory distress requiring intubation and ventilation, then he developed hypotension, bradycardia, and asystole, which required immediate cardiopulmonary resuscitation and atropine. He remained with quadriplegia and suffered from frequent episodes of bradycardia and asystole.
  
  
  CONCLUSIONS
  Spinal AVM rupture can present as neurogenic shock, stunned myocardium, and pulmonary edema. Early recognition of AVM rupture and prompt surgical intervention, as well as aggressive treatment of shock, may enhance recovery and decrease the long-term morbidity.
authors.affiliation: Department of Anesthesia/ICU and Perioperative Medicine, Hamad Medical Corporation, Doha, Qatar.
authors.forename: Tasneem H
authors.initials: TH
authors.lastname: Mehesry
authors.affiliation: Department of Anesthesia/ICU and Perioperative Medicine, Hamad Medical Corporation, Doha, Qatar.
authors.forename: Nissar
authors.initials: N
authors.lastname: Shaikh
authors.affiliation: Department of Anesthesia/ICU and Perioperative Medicine, Hamad Medical Corporation, Doha, Qatar.
authors.forename: Mohammad F
authors.initials: MF
authors.lastname: Malmstrom
authors.affiliation: Department of Anesthesia/ICU and Perioperative Medicine, Hamad Medical Corporation, Doha, Qatar.
authors.forename: Marco A E
authors.initials: MA
authors.lastname: Marcus
authors.affiliation: Department of Neurosurgery Section, Department of Neurosciences, Hamad Medical Corporation, Doha, Qatar.
authors.forename: Adnan
authors.initials: A
authors.lastname: Khan
keywords: Neurogenic pulmonary edema; neurogenic shock; spinal arteriovenous malformation rupture