Unexpected fatal hemodynamic collapse during MRI anaesthesia in an 11-month-old infant with suspected neuroblastoma: a case report

Neuroblastoma is the most common extracranial solid tumours in children, but catecholamine-secreting variants are rare. Unlike pheochromocytoma, routine preoperative α-blockade and extended perioperative monitoring are not recommended for asymptomatic neuroblastoma, as clinically significant catecholamine secretion is considered exceptional. We present a fatal case of hemodynamic collapse during general anaesthesia for magnetic resonance imaging in an infant with undiagnosed catecholamine-secreting neuroblastoma. Subtle preoperative symptoms were present, the risk was underestimated, and lack of preparedness contributed to the outcome. An 11-month-old boy was admitted with failure to thrive, excessive thirst, nocturnal polyuria, and episodes of sweating. He appeared clinically stable except for hypertension (114/91 mmHg) and tachycardia 144 bpm, attributed to agitation. He was underweight (weight 8.1 kg, 3rd percentile) with suspected hepatomegaly. Ultrasound revealed a large abdominal mass suspicious for hepatoblastoma or neuroblastoma. Laboratory values at admittance were normal. The following day, magnetic resonance imaging under general anaesthesia was scheduled. Induction with sevoflurane followed by conversion to total intravenous anaesthesia and intubation was uneventful, but the patient remained tachycardic (150–160 bpm) and hypertensive (151/115 mmHg). Despite fluid bolus, increased anaesthetic depth, and manual tumours displacement tachycardia worsened (up to 240 bpm), prompting abortion of the scan. He subsequently developed hypotension, mottling and cardiac arrest. Resuscitation was unsuccessful. Urinary catecholamine metabolites had been sampled before induction of anaesthesia, but the markedly elevated results were only available after the fatal event (vanillylmandelate 900 µmol/L (reference <12) and homovanillate 197 µmol/L (reference <21)). Autopsy revealed a large adrenal tumours compressing the inferior vena cava. Histology confirmed poorly differentiated neuroblastoma with neuroendocrine differentiation and extensive metastases. This case illustrates a catastrophic manifestation of catecholamine-secreting neuroblastoma, in which general anaesthesia alone unmasked a hypertensive crisis and fatal collapse. Subtle preoperative symptoms were present, but the risk was underestimated, and preparedness for a catecholamine crisis was limited. Vigilance for unexplained hypertension, flushing, or sweating in children with suspected neuroblastoma is essential. When catecholamine secretion is suspected, both preventive strategies and prompt pharmacological treatment of hypertensive crises, including α-blockade and titratable vasodilators, should be considered to prevent rare but devastating events.