Cerebral Infarction Arising from Takotsubo Cardiomyopathy: Case Report and Literature Review

Abstract

changes mimic acute myocardial infarction, characterized by a sudden onset of chest pain and ECG abnormality, with ST elevation or T-wave inversion. Takotsubo cardiomyopathy is diagnosed if left ventricular akinesis or dyskinesis in the absence of significant coronary artery occlusion is observed. Takotsubo cardiomyopathy accounts for approximately 1–3% of patients presenting with symptoms that appear to be an acute coronary syndrome. Although prognosis is generally good, complications including cardiogenic shock or arrhythmia occur in 20–50% of patients, and mortality in 2% of patients. 1–3) Recently, reports of thromboembolic complications in patients with takotsubo cardiomyopathy have been increasing, and the most common type of thromboembolic complications is cerebral infarction. 4) However, neither the timing of thromboembolism resulting from takotsubo cardio-myopathy nor the treatment have been well described. Here, we report a case of cerebral infarction arising from takotsubo cardiomyopathy and review the available literature. Case Report A 44-year-old woman was transferred to the emergency department of our hospital with left hemiparesis and dysar-thria within 1 hour from stroke onset. A few days prior to this, she had felt chest discomfort without etiology, and her chest pain had increased the 4 hours prior to stroke onset. She had no prodrome including illness. In the past, she had been admitted to the department of cardiology in our hospital for acute heart failure with hypertension; when her heart function was improved, echocardiogram had shown no evi-dence of takotsubo cardiomyopathy. She had been prescribed a calcium blocker and angiotensin-converting enzyme inhib-itor by her family doctor and showed no symptoms before stroke onset. She had no other past medical history, but she was smoker. Her neurological symptoms steadily improved on the way to the hospital, and her National Institutes Health Stroke Scale score was 2 at arrival and 0 after magnetic resonance imaging (MRI). Head MRI showed acute infarction in the right insular cortex and occlusion of the right middle cere-bral artery at the M2 segment (Fig. 1A and B). ECG showed ST elevations in leads V2-5 and inverted T-waves in V2-6 (Fig. 2). Laboratory analysis revealed CPK was 773 U/l (normal, 30–170 U/l), CK-MB was 86 IU/l (normal, 0-25 IU/l), BNP was 117 pg/ml (normal, 0–18.4 pg/ml) and levels of troponin-T and fatty acid binding protein were elevated. Although most patients with takotsubo cardiomyopathy have a favorable outcome, complications are not uncommon. Recent studies have reported an increase in incidence of cardioembolic complications; however, the association between takotsubo cardiomyopathy and stroke, in particular thromboembolic cerebral infarction, remains unclear. We reported a 44-year-old woman who had a cerebral infarction resulting from takotsubo car-diomyopathy. She had felt chest discomfort a few days prior to infarction, and later developed left hemiparesis. Head magnetic resonance imaging (MRI) revealed acute infarction in the right insular cortex and occlusion of the right middle cerebral artery at the M2 segment. Echocar-diogram revealed a takotsubo-like shape in the motion of the left ventricular wall, and coronary angiography showed neither coronary stenosis nor occlusion. Cere-bral infarction resulting from takotsubo cardiomyopathy was diagnosed and treatment with anticoagulant was started. MRI on the eighth day after hospitalization showed recanalization of the right middle cerebral artery and no new ischemic lesions. The findings of the 19 previously published cases who had cerebral infarc-tion resulting from takotsubo cardiomyopathy were also reviewed and showed the median interval between takotsubo cardiomyopathy and cerebral infarction was approximately 1 week and cardiac thrombus was detected in 9 of 19 patients. We revealed that thrombo-embolic events occurred later than other complications of takotsubo cardiomyopathy and longer observation might be required due to possible cardiogenic cerebral infarction. Anticoagulant therapy is recommended for patients with takotsubo cardiomyopathy with cardiac thrombus or a large area of akinetic left ventricle.