Takotsubo syndrome after nimodipine-induced hypotension treated with norepinephrine in a female with subarachnoid hemorrhage.

The prevalence of takotsubo syndrome (TTS) in patients with subarachnoid hemorrhage (SAH) is much higher than in the general population. Clinical and experimental observations confirm secondary to brain damage catecholamine-mediated cardiac injury resulting in reversible left ventricular (LV) dysfunction. However, other triggers can also be involved in TTS development e.g. manipulations during surgical or endovascular treatment of a bleeding intracranial aneurysm, concomitant hyponatremia or infection, intubation, blood transfusion and pharmacologic treatment. Nimodipine is recommended in SAH to prevent cerebral arteries vasospasm but can cause hypotension, so vasopressors, e.g. norepinephrine (NE) are commonly used to reach target blood pressure. A CASE REPORT: The authors present a case of a 72-year-old woman with SAH in whom the disease began with a headache, syncope, decreased level of consciousness and vomiting; there were no cardiac symptoms at admission. Endovascular coiling of internal carotid artery aneurysm was performed. On day 2, she developed TTS presenting in echocardiography as apical ballooning; immediately before TTS onset, NE was started to treat nimodipine-induced hypotension. Despite severe heart failure (HF), the patient's neurological status did not deteriorate. HF symptoms remitted after a few days and LV function returned to normal after a week. Negative T waves in ECG which appeared at TTS onset disappeared after 50 days. At that moment no neurological deficits were observed. CONCLUSIONS: The authors underline that in SAH patients nimodipine administration should be cautious to avoid an excessive blood pressure decrease especially in view of further catecholamines use.

ECG pattern in reverse takotsubo cardiomyopathy demonstrated in 5 cases with intracranial hemorrhage.

In typical takotsubo cardiomyopathy (TC) apical transient left ventricular dysfunction with concomitant ECG changes mimicking acute anterior myocardial infarction can be observed. Reverse TC (RTC) characterized by contractile disturbances in all basal and often simultaneous mid-ventricular segments is definitely less frequent. ECG pattern of RTC is less known. The authors present ECG findings in 5 cases of RTC in course of intracranial hemorrhage (ICH); 3 patients were diagnosed with subarachnoid hemorrhage (SAH) and the other two with intracerebral hemorrhage or subdural posttraumatic hematoma. In all patients, initial ECG appearance was dominated by ST segment depression in inferior leads (II, III, avF) and/or lateral leads (V4-6). In 4 patients, concurrent ST segment elevation in avR and avL leads was seen, additionally 4 patients had low QRS voltage in high lateral leads (I, avL). Potential normalization of these changes did not influence the patient`s survival. In one woman, immediately before death, early repolarization was recorded. In subjects with an increased risk of TC, for example in intracranial hemorrhage, particularly in SAH, the ECG abnormalities presented may indicate a need for further search of its atypical echocardiographic variants.