Neurogenic Pulmonary Edema in Intracerebral Hemorrhage: A Systematic Review and a Single-Center Experience from Northeast India

Abstract Background: Neurogenic pulmonary edema (NPE) is a devastating but under-recognized complication of intracerebral hemorrhage (ICH). It results from a sympathetic surge and disruption of pulmonary vascular integrity following neurological insult. Although well described in subarachnoid hemorrhage and traumatic brain injury, literature on NPE in spontaneous ICH remains limited, especially in low- and middle-income countries (LMICs). Objective: To integrate global evidence on the incidence, predictors, and outcomes of NPE in ICH, and to present a decade-long single-center experience from Jorhat Christian Medical Centre (JCMC), Assam, India.Methods: A systematic review following PRISMA guidelines was conducted across PubMed, Embase, Scopus, and Cochrane Library databases until December 2024. Inclusion criteria: clinical studies reporting NPE in ICH; exclusion criteria: case reports and cardiogenic pulmonary edema. Data on incidence, mortality, predictors, and interventions were synthesized. Parallelly, a retrospective cohort study of 67 patients with CT-confirmed ICH complicated by NPE at JCMC between 2015–2024 was analyzed. Variables included demographics, GCS, ICH volume/location, ventilation duration, complications, and mortality. Results: Twenty-one studies were included in the systematic review, reporting NPE incidence of 9–28% and mortality rates of 30–55%. The JCMC cohort demonstrated 44.8% mortality. Independent predictors of mortality were brainstem hemorrhage (OR 3.1), GCS <8 (OR 9.8), ICH volume >30 mL (OR 4.9), and ventilation >5 days (OR 7.5). Complications included ventilator-associated pneumonia (18%), sepsis (9%), acute kidney injury (6%), and electrolyte imbalance (12%).Conclusion: NPE significantly worsens the prognosis of ICH. Our single-center results align with global evidence, underscoring the urgent need for early recognition, aggressive critical care, and multicenter collaboration to establish standardized management protocols, particularly in LMIC contexts.