Takotsubo cardiomyopathy associated with seizures

Hyponatremia and takotsubo syndrome: a review of pathogenetic and clinical implications

Hyponatremia is a common electrolyte abnormality with important prognostic and therapeutic implications. It might exert detrimental effects on various organ systems including the central nervous system (CNS), bone, and heart along with its potential association with poor quality of life. These adverse effects might be largely mediated through a variety of mechanisms including osmotic stress, dysfunctional transmembrane exchangers, and enhanced oxidative stress.Interestingly, hyponatremia might also have an important association with takotsubo syndrome (TTS) that has been universally considered as a reversible form of cardiomyopathy usually emerging in response to various stressors. In this context, severe hyponatremia was previously reported to serve as a direct trigger of TTS evolution largely through its potential impact on CNS and heart. However, pathogenetic and clinical implications of hyponatremia still need to be thoroughly evaluated in patients with TTS. This paper aims to analyze the clinical features of published cases with TTS primarily triggered by hyponatremia and also aims to discuss the association between hyponatremia and TTS from a broader perspective.

Diagnosis and Management of Status Epilepticus

Seizures are among the most common neurological presentations to the emergency room. They present on a spectrum of severity from isolated new-onset seizures to acute repetitive seizures and, in severe cases, status epilepticus. The latter is the most serious, as it is associated with high morbidity and mortality. Prompt recognition and treatment of both seizure activity and associated acute systemic complications are essential to improve the overall outcome of these patients. The purpose of this review is to provide the current viewpoint on the diagnostic evaluation and pharmacological management of patients presenting with status epilepticus, and the common associated systemic complications.

Cardiac stress after electroconvulsive therapy and spontaneous generalized convulsive seizures: A prospective echocardiographic and blood biomarker study

AIM

Knowledge about cardiac stress related to seizures in electroconvulsive therapy (ECT) and spontaneously occurring generalized convulsive seizures (GCS) is limited. The aim of the present study was to analyze cardiac function and circulating markers of cardiac stress in the early postictal period after ECT and GCS.

METHODS

Patients undergoing ECT in the Department of Psychiatry, Psychotherapy and Psychosomatics and patients undergoing diagnostic video-EEG monitoring (VEM) in the Department of Neurology were prospectively enrolled between November 2017 and November 2018. Cardiac function was examined twice using transthoracic echocardiography within 60 min and >4 h after ECT or GCS. Established blood markers (troponin T high-sensitive, N-terminal pro brain natriuretic peptide) of cardiac stress or injury were collected within 30 min, 4 to 6 h, and 24 h after ECT or GCS. In the ECT group, the troponin T values were also correlated with periprocedural heart rate and blood pressure values. Because of organizational or technical reasons, the measurement was not performed in all patients.

RESULTS

Twenty patients undergoing ECT and 6 patients with epilepsy with a GCS during VEM were included. Postictal echocardiography showed no wall motion disorders and no change in left ventricular and right ventricular functions. Four of 17 patients displayed a transient increase in high-sensitive cardiac troponin T 4-6 h after the seizure (3 patients with ECT-induced seizure). None of these 4 patients had signs of an acute cardiac event, and periprocedural blood pressure or heart rate peaks during ECT did not significantly differ in patients with and without troponin T elevation.

CONCLUSIONS

Signs of mild cardiac stress can occur in some patients following ECT or GCS without clinical complications, probably related to excessive catecholamine release during the seizure.

Immediate versus delayed detection of Takotsubo syndrome after epileptic seizures

Takotsubo syndrome(TTS) is often preceded by emotional or physical stress. Epileptic seizures are described in >100 cases. It is unknown whether patients with immediate and delayed detection of seizure-induced TTS differ. We screened the literature and compared clinical and electrocardiographic (ECG) findings. In 48 cases with seizure-associated TTS, the time between seizure and TTS-detection was reported. Troponin levels were elevated in 37/40. ECG abnormalities were negative T-waves(40%), ST-elevations(33%) and ventricular fibrillation/flutter(10%). Immediate detection was reported in 23 patients, in the remaining 25 patients, TTS was detected 5-288 h postictally. Patients did not differ in gender, age or symptoms. Negative T-waves were more frequent in patients with delayed detection(64 vs. 13%, p = .0009), whereas ECG-abnormalities suggesting acute myocardial infarction tended to be more prevalent in patients with immediate detection. Due to lack of typical symptoms, seizure-induced TTS can be overlooked. Postictally, an ECG should be recorded and troponin levels measured. New T-wave inversions might indicate seizure-induced TTS.

Unusual combined cause of Takotsubo cardiomyopathy: Hyponatremia and seizure

Takotsubo cardiomyopathy (TTC) is characterized by transient systolic dysfunction of the left ventricle and changes of electrocardiographic or cardiac markers, resembling an acute coronary syndrome. Although the etiology of TTC is still unknown, a wide variability in the psychological and physical triggers for TTC is present. In this article, we describe the case of 69-year-old female with a history of epilepsy and who presented in the emergency room with a new-onset generalized tonic–clonic seizure activity. After finding out that her biochemistry results indicated severe hyponatremia, a diagnosis of TTC was established through echocardiography and angiography.

Psychiatric Illness in Takotsubo (Stress) Cardiomyopathy: A Review

BACKGROUND

Takotsubo cardiomyopathy (TC), also known as stress-induced cardiomyopathy, has been increasingly described in relation to psychiatric illness.

METHODS

We performed a literature review to identify the key findings related to psychiatric illness in TC that may be relevant to the practice of mental health and other health care providers.

RESULTS

The association of psychiatric illness with TC in addition to the spectrum of psychiatric illness found in TC, the role of exacerbation or treatment of psychiatric illness in triggering TC, different modes of presentation, prognostic implications, and long-term management of psychiatric illness in TC are discussed. Additionally, we review the limitations of the pre-existing literature and suggest areas of future research.

CONCLUSIONS

There is a strong association between pre-existing psychiatric illness, particularly anxiety and mood spectrum disorders, and TC. Acute exacerbation of psychiatric illness, rapid uptitration or overdose of certain psychotropic agents, and electroconvulsive therapy may trigger TC. Further studies are needed to better evaluate the prognostic significance and long-term management of psychiatric illness in TC.

Seizure Associated Takotsubo Syndrome: A Rare Combination

Takotsubo cardiomyopathy (TC) is increasingly recognized in neurocritical care population especially in postmenopausal females. We are presenting a 61-year-old African American female with past medical history of epilepsy, bipolar disorder, and hypertension who presented with multiple episodes of seizures due to noncompliance with antiepileptic medications. She was on telemetry which showed ST alarm. Electrocardiogram (ECG) was ordered and showed ST elevation in anterolateral leads and troponins were positive. Subsequently Takotsubo cardiomyopathy was diagnosed by left ventriculography findings and absence of angiographic evidence of obstructive coronary artery disease. Echocardiogram showed apical hypokinesia, ejection fraction of 40%, and systolic anterior motion of mitral valve with hyperdynamic left ventricle, in the absence of intracoronary thrombus formation in the angiogram. Electroencephalography showed evidence of generalized tonic-clonic seizure. She was treated with supportive therapy. This case illustrates importance of ECG in all patients with seizure irrespective of cardiac symptoms as TC could be the cause of Sudden Unexpected Death in Epilepsy (SUDEP) and may be underdiagnosed and so undertreated.

Clinical Features of Patients with Diffuse Alveolar Hemorrhage due to Negative-Pressure Pulmonary Edema

PURPOSE

Diffuse alveolar hemorrhage (DAH) with negative-pressure pulmonary edema (NPPE) is an uncommon yet life-threatening condition. We aimed at describing the circumstances, clinical, radiological, and bronchoscopic features, as well as the outcome of patients with NPPE-related DAH.

METHODS

We performed a retrospective, observational cohort study, using data prospectively collected over 35 years in an intensive care unit (ICU).

RESULTS

Of the 149 patients admitted for DAH, we identified 18 NPPE episodes in 15 patients, one admitted four times for recurrent NPPE-related DAH. The patients were primarily young, male, and athletic. The NPPE setting was postoperative (n = 12/18, 67%) or following generalized tonic-clonic seizures (n = 6/18, 33%). Hemoptysis was almost constant (n = 17/18, 94%), yet rarely massive (>200 cc, n = 1/18, 6%), with anemia observed in 10 (56%) episodes. The DAH triad (hemoptysis, anemia, and pulmonary infiltrates) was observed in 50% of episodes (n = 9/18), and acute respiratory failure in 94% (n = 17/18). Chest computed tomography revealed diffuse bilateral ground glass opacities (n = 10/10, 100%), while bronchoscopy detected bilateral hemorrhage (n = 12/12, 100%) and macroscopically bloody bronchoalveolar lavage, with siderophage absence in most (n = 7/8, 88%), indicating acute DAH. While one episode proved fatal, the other 17 recovered rapidly, with a mean ICU stay lasting 4.6 (2-15) days. Typically, the evolution was rapidly favorable under supportive care.

CONCLUSION

NPPE-related DAH is a rare life-threatening condition occurring primarily after tonic-clonic generalized seizure or generalized anesthesia. Clinical circumstances are a key to its diagnosis. Early diagnosis and recognition likely allow for successful management of this potentially serious complication, whereas ictal-DAH appears ominous in epileptic patients.

The heart of epilepsy: Current views and future concepts

Cardiovascular (CV) comorbidities are common in people with epilepsy. Several mechanisms explain why these conditions tend to co-exist including causal associations, shared risk factors and those resulting from epilepsy or its treatment. Various arrhythmias occurring during and after seizures have been described. Ictal asystole is the most common cause. The converse phenomenon, arrhythmias causing seizures, appears extremely rare and has only been reported in children following cardioinihibitory syncope. Arrhythmias in epilepsy may not only result from seizure activity but also from a shared genetic susceptibility. Various cardiac and epilepsy genes could be implicated but firm evidence is still lacking. Several antiepileptic drugs (AEDs) triggering conduction abnormalities can also explain the co-existence of arrhythmias in epilepsy. Epidemiological studies have consistently shown that people with epilepsy have a higher prevalence of structural cardiac disease and a poorer CV risk profile than those without epilepsy. Shared CV risk factors, genetics and etiological factors can account for a significant part of the relationship between epilepsy and structural cardiac disease. Seizure activity may cause transient myocardial ischaemia and the Takotsubo syndrome. Additionally, certain AEDs may themselves negatively affect CV risk profile in epilepsy. Here we discuss the fascinating borderland of epilepsy and cardiovascular conditions. The review focuses on epidemiology, clinical presentations and possible mechanisms for shared pathophysiology. It concludes with a discussion of future developments and a call for validated screening instruments and guidelines aiding the early identification and treatment of CV comorbidity in epilepsy.

Changes in vagus nerve activity associated with ictal tachycardia in pigs

OBJECTIVE

Ictal tachycardia (IT) is common and may pave the way towards cardiac conditions with high risk potential. However, the mechanisms of IT remain obscure and therefore difficult to control. For example, whereas IT is associated with a sympathetic surge, it is unclear why the IT effects are not opposed by baroreflex cardiac inhibition during seizures. As the vagus nerves (VN) are main mediators for such baroreflexes, this study was performed to investigate the VN activity in IT.

METHODS

The present experiments were performed in ten pigs where IT seizures were induced by controlled infusion of pentylenetetrazole. The electrocorticogram was recorded using a cranial electrode, the electrocardiogram (ECG) using surface electrodes and the blood pressure (BP) using a catheter inserted in the right carotid artery. The VN activity was recorded from both nerves using cuff electrodes and further analyzed in correlation with the cortical seizures and the associated heart rate (HR), BP and HR variability (HRV) changes.

RESULTS

The cortical seizures progressed from spike-and-wave (SW) to tonic-clonic (TC) discharges associated with ECG, HR and BP changes proportional with this progression and comparable to the IT effects reported in humans. Those IT effects were accompanied by parasympathetic HRV changes, a 20% VN activation (p=0.004) before the onset of TC seizures, a suppression of this VN activation during the TC episode and a rebound VN activation by 79% (left VN, p=0.02) and 57% (right VN, p=0.03) after the TC offset. Further analysis of an afferent BP-related VN component and a mixed VN component showed normal BP-related afferent input and a suppressed efferent output through both nerves during the TC episode.

CONCLUSIONS

This study indicates a suppressed ictal VN activation and a rebound postictal VN activation, which may account for the absence of baroreflexes during seizures and the postictal cardiac inhibition, respectively.

Regenerative Medicine: Potential Mechanisms of Cardiac Recovery in Takotsubo Cardiomyopathy

OPINION STATEMENT

Takotsubo cardiomyopathy is an increasingly reported cause of acute chest pain and acute heart failure and is often associated with significant hemodynamic compromise. The illness is remarkable for the reversibility in systolic dysfunction seen in the disease course. While the pathophysiology of takotsubo syndrome is not completely elucidated, research suggests the presence of a cytoprotective process that allows the myocardium to recover following the inciting insult. Here, we summarize molecular and histologic studies exploring the response to injury in takotsubo disease and provide some discussion on how they may contribute to further investigations in cardiac recovery and regeneration.

Progressive development of cardiomyopathy following altered autonomic activity in status epilepticus

Seizures are associated with altered autonomic activity, which has been implicated in the development of cardiac dysfunction and structural damage. This study aimed to investigate the involvement of the autonomic nervous system in seizure-induced cardiomyopathy. Male Sprague-Dawley rats (320–350 g) were implanted with EEG/ECG electrodes to allow simultaneous telemetric recordings during seizures induced by intrahippocampal (2 nmol, 1 μl/min) kainic acid and monitored for 7 days. Seizure activity occurred in conjunction with increased heart rate (20%), blood pressure (25%), and QTc prolongation (15%). This increased sympathetic activity was confirmed by the presence of raised plasma noradrenaline levels at 3 h post-seizure induction. By 48 h post-seizure induction, sympathovagal balance was shifted in favor of sympathetic dominance, as indicated by both heart rate variability (LF/HF ratio of 3.5 ± 1.0) and pharmacological autonomic blockade. Functional cardiac deficits were evident at 7 and 28 days, as demonstrated by echocardiography showing a decreased ejection fraction (14% compared with control, P < 0.05) and dilated cardiomyopathy present at 28 days following seizure induction. Histological changes, including cardiomyocyte vacuolization, cardiac fibrosis, and inflammatory cell infiltration, were evident within 48 h of seizure induction and remained present for up to 28 days. These structural changes most probably contributed to an increased susceptibility to aconitine-induced arrhythmias. This study confirms that prolonged seizure activity results in acute and chronic alterations in cardiovascular control, leading to a deterioration in cardiac structure and function. This study further supports the need for modulation of sympathetic activity as a promising therapeutic approach in seizure-induced cardiomyopathy.

Cardiac and autonomic mechanisms contributing to SUDEP

Sudden unexpected death in epilepsy is likely caused by a cascade of events affecting the vegetative nervous system leading to cardiorespiratory failure and death. Multiple genetic, electrophysiological, neurochemical, and pharmacological cardiac alterations have been associated with epilepsy, which can affect autonomic regulation of the heart and predispose patients to sudden unexpected death in epilepsy. These cardiac and autonomic changes are more frequently seen in patients with longstanding and medication refractory epilepsy and may be a prerequisite for sudden unexpected death in epilepsy. Cardiac changes are also observed within the immediate periictal period in patients with and without preexisting cardiac pathology and could be the tipping point in the cascade of events compromising autonomic, respiratory, and cardiac function during an epileptic convulsion. Better understanding if and how these cardiac alterations can make a particular individual with epilepsy more susceptible to sudden unexpected death in epilepsy will hopefully lead us to more effective preventative strategies.

CNS disease triggering Takotsubo stress cardiomyopathy

There are a number of hereditary and non-hereditary central nervous system (CNS) disorders, which directly or indirectly affect the heart (brain-heart disorders). The most well-known of these CNS disorders are epilepsy, stroke, infectious or immunological encephalitis/meningitis, migraine, and traumatic brain injury. In addition, a number of hereditary and non-hereditary neurodegenerative disorders may impair cardiac functions. Affection of the heart may manifest not only as arrhythmias, myocardial infarction, autonomic impairment, systolic dysfunction/heart failure, arterial hypertension, or pulmonary hypertension, but also as stress cardiomyopathy (Takotsubo syndrome, TTS). CNS disease triggering TTS includes subarachnoid bleeding, epilepsy, ischemic stroke, intracerebral bleeding, migraine, encephalitis, traumatic brain injury, PRES syndrome, or ALS. Usually, TTS is acutely precipitated by stress triggered by various different events. TTS is one of the cardiac abnormalities most frequently induced by CNS disorders. Appropriate management of TTS from CNS disorders is essential to improve the outcome of affected patients.

The multifaceted care of status epilepticus

After seizures have been controlled, long-term care of status epilepticus may be needed and collectively involves every major organ. First, as a result of rapid escalation of antiepileptic drugs, there are initial concerns with hypotension, acid-base abnormalities, and cardiac arrhythmias. Second, refractory status epilepticus and the continuous need for intravenous administration of anesthetic drugs will lead to a multitude of systemic complications that require long-term complex care. Most anticipated problems are infectious complications with a high risk of pneumonia and sepsis, but thromboembolism due to immobilization and catheter placement are also common. If a good outcome is possible or anticipated in a patient with refractory status epilepticus, physicians should plan for a surveillance and treatment protocol to adequately support these patients.

Infective rhomboencephalitis and inverted Takotsubo: neurogenic-stunned myocardium or myocarditis?

Here we originally describe the clinical scenario of a young immune-competent patient affected by acute rhomboencephalitis with severe parenchymal edema and acute hydrocephalus who developed sudden life-threatening cardiac derangement. Hemodynamic and perfusion parameters revealed cardiogenic shock, so intensive circulatory support with epinephrine infusion and intra-aortic balloon pump was needed to restore organ perfusion. Transesophageal echocardiographic examination showed severe left ventricular dysfunction (ejection fraction as low as 20%) with wall motion abnormalities resembling a pattern of Takotsubo-inverted cardiomyopathy. Cultural investigations revealed infection by Listeria monocytogenes. Nevertheless, her conditions rapidly improved, and she had full cardiac recovery within few days. Acute cerebral damage, pattern of echocardiographic wall motion abnormalities, and clinical course may suggest neurogenic stunned as pathological mechanism responsible for cardiac dysfunction, but differential diagnosis with acute myocarditis is to be considered too. Acute cardiogenic shock during the course of rhomboencephalitis by L monocytogenes has not been yet reported; prompt clinical suspicion and intensive care are needed to manage this life-threatening condition.

Hyponatremia--an unusual trigger of Takotsubo cardiomyopathy

Takotsubo cardiomyopathy is an acute cardiac entity with clinical manifestations similar to myocardial infarction, accounting for 1-2% of acute coronary syndrome admissions. Its underlying pathophysiology is not yet well established. It is usually associated with acute physical or emotional stress, but the list of potential triggers has grown as the condition attracts the attention of the medical community. In order to diagnose the condition correctly and to gain new insights into it, we need to know its potential triggers as well as its clinical presentation and diagnostic criteria. We report a case of takotsubo cardiomyopathy triggered by hyponatremia.

Takotsubo cardiomyopathy: its possible impact during adult donor care

Takotsubo cardiomyopathy, the syndrome caused by an extreme release and circulation of catecholamines, shares several histopathological and clinical similarities with cardiac changes after brain death noted in animal investigations and human observation. Overwhelming stimulation of myocardial inotropic β receptors may alter their responsiveness and induce other biochemical processes, producing reduced cardiac contractility. Treatment methods in Takotsubo cardiomyopathy that use extracorporeal circulatory support and medications that do not rely on β-receptor stimulation and preemptive blockade of β receptors or calcium channels before brain death may be relevant to donor care.

β adrenergic blockade prevents cardiac dysfunction following status epilepticus in rats

Status epilepticus (SE) can result in temporary cardiac dysfunction in patients, characterized by reduced ejection fraction, decreased ventricular contractility, and alterations in electrical activity of the heart. Although reversible, the cardiac effects of seizures are acutely life threatening, and may contribute to the delayed mortality following SE. The precise mechanisms mediating acute cardiac dysfunctions are not known. These studies evaluated effects of self-sustaining limbic SE in rats on cardiac performance 24h following seizures, and determined if sympathetic nervous system activation during seizures contributed to cardiac dysfunction. Rats subjected to SE received either vehicle (saline) or the B1 adrenergic antagonist atenolol (AT) prior to and during 90 min of seizure activity. Control rats were similarly treated, except they did not undergo seizures. Twenty-four hours after SE, animals were anesthetized and catheterized for measurement of cardiac performance variables. Animals undergoing SE demonstrated significantly reduced cardiac output, decreased ventricular contractility and relaxation, increased blood pressure, and prolonged QT interval. However, heart rate was not altered. Treatment with AT prevented all changes in cardiac performance due to SE, and attenuated the increase in QT interval. These data demonstrate that SE in the rat results in cardiac dysfunction 24h following seizures, mediated by the sympathetic nervous system.

Takotsubo Cardiomyopathy: Its Possible Impact during Adult Donor Care

Takotsubo cardiomyopathy, the syndrome caused by an extreme release and circulation of catecholamines, shares several histopathological and clinical similarities with cardiac changes after brain death noted in animal investigations and human observation. Overwhelming stimulation of myocardial inotropic β receptors may alter their responsiveness and induce other biochemical processes, producing reduced cardiac contractility. Treatment methods in Takotsubo cardiomyopathy that use extracorporeal circulatory support and medications that do not rely on β-receptor stimulation and preemptive blockade of β receptors or calcium channels before brain death may be relevant to donor care.

Recurrent takotsubo cardiomyopathy in the setting of transient neurological symptoms: a case report

Introduction

First described in Japan, takotsubo cardiomyopathy is increasingly becoming recognized worldwide as a cause of sudden and reversible diminished left ventricular function characterized by left apical ballooning and hyperkinesis of the basal segments, often with symptoms mimicking a myocardial infarction. Associated with physical or emotional stress, its exact pathogenesis has not been established, though evidence supports a neurohumoral etiology. Additionally, recurrence of this condition is rare. In this report, we present a rare case of recurrent takotsubo cardiomyopathy in a post-menopausal woman who presented with transient neurological complaints on both occasions.

Case presentation

We present a rare case of a 76-year-old Caucasian woman with no history of congestive heart failure who presented to our emergency department twice with transient neurological complaints. On the first occasion, she was found to have transient aphasia which resolved within 24 hours, yet during that period she also developed symptoms of congestive heart failure and was noted to have a new, significantly depressed ejection fraction with apical akinesis and possible apical thrombus. One month after her presentation a repeat echocardiogram revealed complete resolution of all wall motion abnormalities and a return to baseline status. Seven months later she presented with ataxia, was diagnosed with vertebrobasilar insufficiency, and again developed symptoms and echocardiography findings similar to those of her first presentation. Once again, at her one-month follow-up examination, all wall motion abnormalities had completely resolved and her ejection fraction had returned to normal.

Conclusion

Though the exact etiology of takotsubo cardiomyopathy is unclear, a neurohumoral mechanism has been proposed. Recurrence of this disorder is rare, though it has been reported in patients with structural brain abnormalities. This report is the first to describe recurrent takotsubo cardiomyopathy in a patient with transient neurological symptoms. In our patient, as expected in patients with this condition, complete resolution of all left ventricular abnormalities occurred within a short period of time. It is important for clinicians to be aware of this increasingly recognized syndrome, including its association with recurrence, especially in the clinical setting of neurologic dysfunction.

Seizure-associated Takotsubo cardiomyopathy

Takotsubo cardiomyopathy is characterized by chest pain, dyspnea, electrocardiographic changes resembling an acute coronary syndrome, and transient wall-motion abnormalities without identifiable coronary culprit lesion explaining the wall-motion abnormality. Takotsubo cardiomyopathy occurs frequently after emotional or physical stress. Seizures have been reported as triggers of takotsubo cardiomyopathy. It is unknown if seizure-associated takotsubo cardiomyopathy differs from takotsubo cardiomyopathy associated with other triggers. Seizure-associated takotsubo cardiomyopathy cases from the literature were compared with takotsubo cardiomyopathy series comprising 30 or more patients. Thirty-six seizure-associated takotsubo cardiomyopathy cases (6 male, mean-age 61.5 years) were found. Seizure-type were tonic-clonic (n = 13), generalized (n = 5), status epilepticus (n = 6), grand mal (n = 2), or not reported (n = 13). Twelve patients had a history of epilepsy, in 15 patients takotsubo cardiomyopathy-associated seizure was the first or the information was not given (n = 9). In 17 patients takotsubo cardiomyopathy occurred immediately after the seizure, in 9 patients 1-72 h postictally, and in 10 patients, the interval was not reported. In 20 patients neurologic disorders were reported and in 14 psychiatric disorders were reported. There were medical comorbidities in 17 patients, arterial hypertension (n = 11), hyponatremia (n = 2), and cancer (n = 2). Compared with 974 patients reported in takotsubo cardiomyopathy -series, patients with seizure-associated takotsubo cardiomyopathy were younger (61.5 vs. 68.5 years, p < 0.0001), more frequently males (17 vs. 9%, p = 0.004), had less frequent chest pain (6 vs.76%, p < 0.005), more frequent cardiogenic shock (25 vs. 8%, p = 0.003), and more frequent recurrency (14 vs. 3%, p = 0.004). Seizure-associated takotsubo cardiomyopathy manifests frequently as sudden hemodynamic deterioration, which could result in death in the absence of adequate help. Probably some cases of sudden unexpected death in epilepsy are attributable to takotsubo cardiomyopathy.

Takotsubo cardiomyopathy in a patient with severe hyponatremia associated with syndrome of inappropriate antidiuretic hormone

Although the etiology of Takotsubo cardiomyopathy (stress-induced cardiomyopathy) is unknown, there is a wide variability in the psychological and physical triggers for Takotsubo cardiomyopathy. We report here a case of Takotsubo cardiomyopathy associated with severe hyponatremia.

Clinicopathological conference: A 71-year-old female with neurological deficits, chest pain, and electrocardiographic changes

The authors present a case of a 71-year-old female who presented to the emergency department with slurred speech, left sided facial droop, and right arm and leg weakness. During her ED stay, she developed left sided chest pain and right arm numbness in the setting of EKG changes. The patient's clinical course is outlined and a discussion of the potential etiologies as well as the clinical management is provided.

Autonomic alterations and cardiac changes in epilepsy

Studies with heart rate variability have revealed interictal autonomic alterations in patients with epilepsy. In addition, epilepsy is frequently associated with ictal tachycardia or bradycardia, which sometimes precedes the onset of seizures. Ictal tachycardia is sometimes associated with electrocardiography (ECG) morphologic changes and ictal bradycardia often progresses to asystole. Such cardiac manifestations of seizures have been hypothesized as possible causes for sudden unexplained death in epilepsy (SUPEP). The present review relates to interictal and ictal cardiac manifestations of epilepsy with focus on heart rate, heart rate variability, and ECG changes. Aspects of the supporting mechanisms are discussed and attention is drawn to the interaction between central and peripheral effects, interictal autonomic conditions, ictal autonomic discharges, and administration of antiepileptic drugs in shaping the ictal cardiac changes. Because these interactions are complex and not totally understood, closer surveillance of patients and more experimental work is necessary to elucidate the mechanistic support of autonomic and cardiac changes in epilepsy, and to design better strategies to avoid their undesirable effects. It is also suggested that some of these changes could be used as predictors or markers for the onset of seizures.

Apical ballooning resulting from limbic encephalitis

BACKGROUND

Neurogenic stunned myocardium is an increasingly recognized cause of left ventricular apical ballooning, or takotsubo cardiomyopathy. We report the first case of neurogenic stunned myocardium as a result of limbic encephalitis.

METHODS

This 73-year-old woman with anterograde and retrograde amnesia was investigated using electrocardiography, magnetic resonance imaging, and left ventricular angiography.

RESULTS

Electrocardiography showed deep T-wave inversions in multiple leads, magnetic resonance imaging demonstrated increased signal on fluid-attenuated inversion recovery images symmetrically within the medial temporal lobes consistent with limbic encephalitis. Left ventricular angiography showed apical ballooning.

CONCLUSIONS

Because the insula has extensive interconnections with limbic structures, limbic encephalitis could lead to alterations in the sympathetic regulation of the insular cortex resulting in neurogenic stunned myocardium.