SESSION TYPE: Critical Care Student/Resident Case Report Posters II
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Tako-tsubo cardiomyopathy (TCM) is a cause of transient, reversible left ventricular dysfunction first recognized as a clinical entity in Japan in the early 1990s. It involves apical hypokinesis with basal sparing and has been classically described in post menopausal women with an emotional stressor. Its association with sub-arachnoid hemorrhage (SAH) has been widely reported. TCM post ischemic stroke is very rare.
CASE PRESENTATION: A 41 year old lady with obstructive sleep apnea was clinically found to have a large neck mass. MRI and CT angiogram of the neck showed a 6cm left carotid body tumor encroaching the pharynx. It was decided to electively resect the tumor in view of its symptomatic nature. She underwent successful pre-operative embolization followed by resection of the tumor (Fig.1). Intra-operatively she developed right sided hemi-paresis and was found to have acute middle cerebral artery (MCA) occlusion. Emergency extra-cranial-intracranial bypass surgery was done between the left superficial temporal artery and the left MCA. At this time, the patient became severely hypotensive. An echocardiogram showed left ventricular (LV) apical akinesis and ballooning with an ejection fraction of 15%. (Fig.2) An intra-aortic balloon pump (IABP) was placed, and a coronary angiogram was performed showing completely normal coronary arteries, with apical ballooning. An echocardiogram, done 3 days post-procedure, showed improving LV contractility and ejection fraction of 25%. This suggests Tako-tsubo cardiomyopathy.
DISCUSSION: A Japanese study showed the incidence of Tako-tsubo cardiomyopathy in acute stroke patients to be 1.2%, similar in incidence to patients with SAH (1). In that study it was found that all of the patients that had Tako-tsubo cardiomyopathy were female and had severe MCA strokes. The precise cause is still unknown, but hypotheses relating to catecholamine-induced myocardial stunning, ischemia-mediated stunning caused by multivessel epicardial or microvascular spasm, and myocarditis have been postulated. The prognosis for Tako-tsubo cardiomyopathy is favorable, if appropriate supportive care is provided in the acute phase. There have been three earlier case reports of the successful use of the IABP in the acute phase of Tako-tsubo cardiomyopathy (2). In our case, the implantation of the IABP helped stabilize the patient’s hemodynamics until her cardiac function improved.
CONCLUSIONS: To the best of our knowledge, only 10 cases of Tako-tsubo cardiomyopathy post acute ischemic stroke have been reported, most of them being MCA strokes (1). Our case is the first reported incidence of Tako-tsubo cardiomyopathy occurring after extra cranial-intra cranial bypass for acute MCA occlusion.
1) Yoshimura S et al; Tako-tsubo Cardiomyopathy in acute ischemic stroke. Ann Neurol 64: 547-554, 2008.
2) Franziska MK et al; Tako-tsubo cardiomyopathy after cerebral aneurysm rupture. J Neurosurg Anaesthesiol 22: 181-182, 2010.
DISCLOSURE: The following authors have nothing to disclose: Mohan Ashok Kumar, Cameron McDougall, Priya Radhakrishnan, Richard Sue
No Product/Research Disclosure InformationInternal Medicine, St. Joseph's Hospital, Phoenix, AZ