Neurogenic Stunned Myocardium in Subarachnoid Hemorrhage

Authors

  • Daniel Bergeron Oklahoma State University Center for Health Sciences College of Osteopathic Medicine (OSU-COM)
  • John Evans Oklahoma State University Medical Center
  • Stephen Dixon Oklahoma State University Medical Center

Keywords:

Neurogenic stunned myocardium, subarachnoid hemorrhage

Abstract

Neurogenic stunned myocardium is a triad of reversible left ventricular dysfunction, electrocardiogram changes and elevation of cardiac enzymes. Clinically, this provides diagnostic challenges in the setting of subarachnoid hemorrhage (SAH) due to the diagnostic uncertainty. The pathophysiological mechanisms for neurogenic stunned myocardium have included hypothalamic and myocardial perivascular lesions. More recently, alternative research has focused on myocardial microvascular dysfunction and genetic polymorphisms. Management has remained largely supportive with case reports citing the benefits of inotropes and intra-aortic balloon pumps in the setting of cardiogenic shock complicating NSM. When NSM follows SAH there are numerous complications, including pulmonary edema, arrhythmias and prolonged intubation, which can impact outcomes and increase morbidity and mortality. This highlights the need for accurate and timely diagnosis of NSM which has remained a clinical challenge. We report a case of a 52-year-old patient who presented to the ICU with complaints of atypical chest pain without neurologic complaints or lateralizing symptoms. She was admitted to the ICU for ongoing chest pain with concurrent ECG T-wave inversions. Within 24 hours she developed lateralizing neurologic signs and altered mental status with subsequent imaging revealing evidence of a SAH. We describe characteristics and outcomes of NSM in this patient with aneurysmal associated SAH.

References

Stegmayr B, Eriksson M, Asplund K. Declining mortality from subarachnoid hemorrhage: changes in incidence and case fatality from 1985 through 2000. Stroke 2004; 35:2059.

Tidswell P, Dias PS, Sagar HJ, et al. Cognitive outcome after aneurysm rupture: relationship to aneurysm site and perioperative complications. Neurology 1995; 45:875.

(Gorelick PB, 1986) Fontanarosa PB. Recognition of subarachnoid hemorrhage. Ann Emerg Med 1989; 18:1199.

Schievink WI. Intracranial aneurysms. N Engl J Med 1997; 336:28.

Butzkueven H, Evans AH, Pitman A, et al. Onset seizures independently predict poor outcome after subarachnoid hemorrhage. Neurology 2000; 55:1315.

Linn FH, Wijdicks EF, van der Graaf Y, et al. Prospective study of sentinel headache in aneurysmal subarachnoid haemorrhage. Lancet 1994; 344:590.

Morgenstern LB, Luna-Gonzales H, Huber JC Jr, et al. Worst headache and subarachnoid hemorrhage: prospective, modern computed tomography and spinal fluid analysis. Ann Emerg Med 1998; 32:297.

McCarron MO, Alberts MJ, McCarron P. A systematic review of Terson's syndrome: frequency and prognosis after subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 2004; 75:491.

Jain R, Deveikis J, Thompson B. Management of Patients with Stunned Myocardium Associated with Subarachnoid Hemorrhage. American Journal of Neurology 25:126-129, January 2004.

Shimizu M, Kagawa A, Takano T, Masai H, Miwa Y. Neurogenic Stunned myocardium Associated with Status Epileptics and Postictal Catecholamine Surge. Internal Medicine. 2008; 47:269-273.

Guglin M, Novotorova I. Neurogenic Stunned Myocardium and Tokotsubo Cardiomyopathy are the Same Syndrome: A Pooled Analysis. Congestive Heart Failure. 2011; 17: 127-132.

Kloner R, Arimie R, Kay G, et al. Evidence for Stunned Myocardium in Humans: a 2001 update. Coronary Art Disease. 2001; 12:349-356.

Mayer S, Lin J, Shunichi H, et al. Myocardial Injury and Left Ventricular Performance after Subarachnoid Hemorrhage. Stroke. 1999; 30:780-786.

Murthy S, Shah S, Venkatasubba R, et al. Neurogenic Stunned Myocardium Following Acute Subarachnoid Hemorrhage. Journal of Intensive Care Medicine. 2013; 30:318-325.

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Published

2017-10-16

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Section

Medical