Acute intraoperative neurogenic myocardial stunning during intracranial endoscopic fenestration and shunt revision in a pediatric patient.

Neurogenic stunned myocardium (NSM) is syndrome of myocardial dysfunction following an acute neurological insult. We report a case of NSM that occurred intraoperatively in a pediatric patient undergoing endoscopic fenestration and shunt revision. Accidental outflow occlusion of irrigation fluid and ventricular distension resulted in an acute increase in heart rate and arterial blood pressure. Subsequently, the patient developed stunned myocardium with global myocardial hypokinesia and pulmonary edema. She was promptly treated intraoperatively then admitted to the pediatric intensive care unit with resolution of her symptoms within 12 h. She was later discharged to home on the fourth postoperative day. In the current endoscopic era, this report highlights the possibility of intraoperative NSM and neurogenic pulmonary edema in the pediatric population. Early detection and treatment with a team approach help to achieve optimal control of this life-threatening condition and improve the outcome.

Ketogenic diet: rapid onset of selenium deficiency-induced cardiac decompensation.

Selenium-deficiency cardiomyopathy is a known secondary complication from long-term treatment with a ketogenic diet for medical refractory epilepsy. Our patient, a 5-year-old boy on a ketogenic diet for intractable seizures, had a normal selenium level before starting the diet, but he shortly thereafter developed acute reversible cardiomyopathy and ventricular tachycardia, which was unmasked during a hospitalization for an elective operative procedure. His cardiomyopathy was suspected to be secondary to a selenium-deficient state and was confirmed by way of a markedly low serum selenium level and supported by rapid improvement with the initiation of selenium supplementation and cessation of the ketogenic diet. For patients being initiated on a ketogenic diet, current screening guidelines call for baseline and follow-up selenium levels every 3 months during the first year along with RDA selenium supplementation, which is 30 mcg/day. Most of the new ketogenic diet formulas meet this requirement. Our patient underwent elective surgery before his planned 3-month selenium level check and had potentially preventable complications. Secondary to this experience, we suggest that all patients initiated on a ketogenic diet should have a preoperative electrocardiogram (EKG), an echocardiogram, and selenium level determined before any elective surgery. These steps would prevent unnecessary perioperative morbidity and mortality.