Acute neurogenic stunned myocardium in a patient with Guillain-Barré syndrome: case report

Autonomic dysfunction is a prevalent symptom of Guillain-Barré syndrome (GBS); cardiovascular involvement in this scenario has been mentioned infrequently in the literature.

Case Presentation

A 65-year-old man with GBS presented with reversible left ventricular systolic failure. On first presentation, our patient had no history or indications of heart malfunction. During the clinical manifestation of his autonomic dysfunction, he had electrocardiographic alterations, modestly increased cardiac enzymes, significant left ventricular systolic dysfunction, and segmental wall motion irregularity. Once the initial episode was over, these anomalies and his symptoms resolved quickly.

Discussion

We believe the reversible left ventricular dysfunction was caused by the toxic impact of elevated catecholamines as well as transiently injured sympathetic nerve endings in the myocardium, which was apparently caused by GBS. We recommend that echocardiography be performed in patients who exhibit clinical signs of autonomic dysfunction, particularly if they are associated with abnormal electrocardiographic findings, cardiac enzyme elevation, or hemodynamic instability, so that appropriate medical therapy can be instituted as soon as possible.

Conclusion

GBS is a not a very rare situation in our context. Thus, doctors are supposed to know the life-threatening complications such as neurogenic stunned myocardium and be prepared to dodge it.

Takotsubo Cardiomyopathy in a Polytrauma Patient With Subarachnoid Hemorrhage

Takotsubo cardiomyopathy (TCM) is a sudden, transient myocardial stunning precipitated by severe emotional or physical stress. It is characterized by left ventricular apical ballooning and elevated cardiac enzymes without significant coronary artery stenosis. Stress-induced catecholamine surge has been proposed to be the likely mechanism of TCM. We report the case of a 23-year-old female who presented to the emergency department unconscious and in respiratory distress following a motor vehicle accident. The point-of-care ultrasonography showed prominent B lines in bilateral lung fields and a dilated inferior vena cava (IVC). An x-ray and computed tomography (CT) scan of the chest revealed bilateral diffuse ground glass opacities. A CT scan of the brain showed a subarachnoid hemorrhage (SAH). Electrocardiography (ECG) showed normal sinus rhythm, but troponin I was elevated. Echocardiography revealed left ventricular apical hypokinesia. The coronary angiogram was normal. A diagnosis of TCM with SAH was made. Appropriate emergent care was provided, and at follow-up, she made a complete cardiologic recovery. TCM is a puzzling condition in an emergency setting and accurate and timely diagnosis is imperative in the management. Early prevention of hypoxemia and maintenance of mean arterial pressure and cerebral perfusion pressure is critical in determining the long-term outcome of the patient in the setting of co-existing CNS pathologies.

Cardiac patterns for differentiation of neurogenic stunned myocardium in aneurysmal subarachnoid hemorrhage versus acute ischemic stroke

AIMS

Neurogenic stunned myocardium (NSM) has heterogeneous presentations for acute ischemic stroke (AIS) and aneurysmal subarachnoid hemorrhage (SAH). We sought to better define NSM and differences between AIS and SAH by evaluating individual left ventricular (LV) functional patterns by speckle tracking echocardiography (STE).

METHODS

We evaluated consecutive patients with SAH and AIS. Via STE, LV longitudinal strain (LS) values of basal, mid, and apical segments were averaged and compared. Different multivariable logistic regression models were created by defining stroke subtype (SAH or AIS) and functional outcome as dependent variables.

RESULTS

One hundred thirty-four patients with SAH and AIS were identified. Univariable analyses using the chi-squared test and independent samples t-test identified demographic variables and global and regional LS segments with significant differences. In multivariable logistic regression analysis, when comparing AIS to SAH, AIS was associated with older age (OR 1.07, 95% CI 1.02-1.13, p = 0.01), poor clinical condition on admission (OR 7.74, 95% CI 2.33-25.71, p < 0.001), decreased likelihood of elevated admission serum troponin (OR .09, 95% CI .02-.35, p < 0.001), and worse LS basal segments (OR 1.18, 95% CI 1.02-1.37, p = 0.03).

CONCLUSION

In patients with neurogenic stunned myocardium, significantly impaired LV contraction by LS basal segments was found in patients with AIS but not with SAH. Individual LV segments in our combined SAH and AIS population were also not associated with clinical outcomes. Our findings suggest that strain echocardiography may identify subtle forms of NSM and help differentiate the NSM pathophysiology in SAH and AIS.

A Rare Case of Postoperative Extradural Hematoma in the Posterior Fossa Complicated by Both Stunned Myocardium and Neurogenic Pulmonary Edema

Acute neurological insult can trigger a cascade of events in other organ systems such as the heart and lung. Neurogenic stunned myocardium (NSM) and Neurogenic pulmonary edema (NPE) are mostly reported after stroke, subarachnoid hemorrhage, or seizures whenever sympathetic storm and autonomic dysregulation occurs. We report here for the first time, a case of postoperative infratentorial extradural hematoma in a patient triggering NSM and NPE at the same time. The challenges involved in the management of such a patient are described in this case report. The patient was successfully managed and discharged home with no new neurological deficits.

Neurogenic Stunned Myocardium: A Review

Neurogenic stunned myocardium is a form of stress cardiomyopathy. The disorder is sometimes referred to as atypical Takotsubo cardiomyopathy. The pathophysiology of neurogenic stunned myocardium is hypothesized to involve significant overdrive of the sympathetic nervous system after a brain injury. Treatment options for a patient with a brain injury who has progressed to cardiogenic shock remain controversial, with no consistent guidelines. A patient with subarachnoid hemorrhage who progresses to cardiogenic shock with concurrent cerebral vasospasm presents a special treatment challenge. Neurogenic stunned myocardium is reversible; however, it must be recognized immediately to avoid or manage potential complications, such as cardiogenic shock and pulmonary edema. A multifaceted treatment approach is needed for the patient with cardiogenic shock and concurrent vasospasm.

Plasma catecholamine levels in the acute and subacute stages of takotsubo syndrome: Results from the Stockholm myocardial infarction with normal coronaries 2 study

AIMS

It is well-accepted that takotsubo syndrome (TS) is characterized by a massive surge of plasma catecholamines despite lack of solid evidence. The objective of this study was to examine the hypothesis of a massive catecholamine elevation in TS by studying plasma-free catecholamine metabolites in patients participating in the Stockholm myocardial infarction (MI) with normal coronaries 2 (SMINC-2) study where TS constituted more than one third of the patients.

METHODS AND RESULTS

The patients included in the SMINC-2 study were classified, according to cardiac magnetic resonance (CMR) imaging findings (148 patients), which was performed at a median of 3 days after hospital admission. Plasma-free catecholamine metabolites; metanephrine, normetanephrine, and methoxy-tyramine were measured on day 2-4 after admission. Catecholamine metabolite levels were available in 125 patients. One hundred and ten (88%) of the 125 patients included in SMINC-2 study, and 38 (86.4%) of the 44 patients with TS had completely normal plasma metanephrine and normetanephrine levels. All patients had normal plasma methoxy-tyramine levels. Fourteen (11.2%) of the 125 patients included in SMINC-2 study, and 5 (11.6%) of the 43 patients with TS had mild elevations (approximately 1.2 times the upper normal limits) of either plasma metanephrine or normetanephrine. One patient with pheochromocytoma-triggered TS had marked elevation of plasma metanephrine and mild elevation of plasma normetanephrine. There were no significant differences between the number or degree of catecholamine metabolite elevations between the different groups of patients with CMR imaging diagnosis included in SMINC-2 study.

CONCLUSION

There was no evidence of massive catecholamine elevations in the acute and subacute stages of TS apart from one patient with pheochromocytoma-induced TS. Most of the TS patients had normal catecholamine metabolites indicating that blood-borne catecholamines do not play a direct role in the pathogenesis of TS.

Neurogenic Stunned Myocardium Following an Attempt to Pass a Drug Test

Ingestion of a large volume of free water or other hypotonic solution can cause acute hyponatremia, leading to multiorgan dysfunction. Individuals may attempt to generate a false-negative urine drug screen through increased free water consumption leading to acute hyponatremia requiring emergency medical care. We present the case of a 19-year-old male who presented to a community emergency department for altered mental status after an attempt to generate a false-negative urine drug screen. He ingested a large volume of free water and multiple detoxification solutions, causing acute hyponatremia with resultant cerebral edema and neurogenic stunned myocardium. He required extracorporeal membrane oxygenation therapy with complete recovery of neurologic and cardiac function. Acute hyponatremia from excess free water consumption is a well-documented phenomenon that all emergency providers should be aware of. Prompt identification and management of acute hyponatremia are essential to prevent potentially severe, devastating sequelae, including cerebral edema and cardiopulmonary failure.In addition, extracorporeal membrane oxygenation may be considered in patients with cardiopulmonary failure in the setting of reversible cardiomyopathy, as evidenced in our case.

Neurogenic Stunned Myocardium in Two Children with Neurological Injury

Neurogenic stunned myocardium is described as sudden and reversible cardiac dysfunction induced by an acute neurological event. This phenomenon has not been thoroughly investigated in infants, and is probably underdiagnosed. Here, we report the cases of two infants with neurogenic stunned myocardium in whom the clinical suspicion was relevant, with a brief discussion of this condition.

The spectrum of acute cardiopulmonary events associated with multiple sclerosis exacerbations

Diverse acute neurological injuries may cause acute cardiopulmonary events including neurogenic pulmonary edema (NPE) and neurogenic stunned myocardium (NSM). The mechanism is probably mediated by sympathetic nervous system activation. Focal central nervous system (CNS) lesions, such as demyelinating lesions in multiple sclerosis (MS), may also cause cardiopulmonary disturbances. We aim to review the acute cardiopulmonary events associated with MS relapses. We performed a literature search using PubMed, and selected case reports of acute cardiac and/or pulmonary events related to MS exacerbations. We grouped these events into three categories: 1) NPE with normal cardiac function; 2) NSM and Takotsubo cardiomyopathy (TTC); 3) coexisting myocardial dysfunction and pulmonary edema. In some cases, cardiac and pulmonary symptoms preceded the onset of neurological symptoms. The majority of cases were associated with acute demyelinating lesions located in the medulla. Acute brainstem MS relapses, with demyelinating lesions affecting the medulla, may cause acute cardiac and pulmonary events presumably secondary to sympathetic hyperstimulation. Specific regions in the medulla that regulate cardiac function, systemic blood pressure and pulmonary hydrostatic pressure seem to be responsible for these events.

The utility of serial echocardiograms for organ procurement in brain death

Heart transplantation rates are limited by a shortage of donor hearts, and left ventricular dysfunction is an important cause. We hypothesized that an early echocardiographic evaluation in severe brain injury (performed within 12 hours from ICU admission) could allow the detection of potentially reversible left ventricular (LV) abnormalities and thus the initiation of tailored treatment whose effects could be assessed at a second echocardiogram performed when brain death develops. We assessed this hypothesis in 49 patients with severe brain injury who were potential heart donors. A reduction in LV ejection fraction (LVEF) (<55%) was present in five patients (10.2%): diffuse hypokinesia in three patients (6.1%), segmental wall motion abnormalities in two (4.1%). Two patients showed apical ballooning (normal LVEF). The three patients with diffuse hypokinesia showed, at the echocardiogram performed 12 hours later, a complete recovery of wall motion and LVEF. Among patients with apical ballooning, a complete resolution was observed in both patients. Two patients were considered potentially eligible for heart donation, resulting in 20% increase in donor retrieval rate. In serious encephalic lesions, potentially evolving toward brain death, echocardiography performed after ICU admission allowed the identification of LV abnormalities, which could be specifically treated with complete resolution.

Neurocardiology

Neurocardiology refers to the interplay between the nervous system and the cardiovascular system. Stress-related cardiomyopathy exemplifies the brain-heart connection and occurs in several conditions with acute brain injury that share oversympathetic activation. The brain's influences on the heart can include elevated cardiac markers, arrhythmias, repolarization abnormalities on electrocardiogram, myocardial necrosis, and autonomic dysfunction. The neurogenic stunned myocardium in aneurysmal subarachnoid hemorrhage represents one end of the spectrum, and is associated with an explosive rise in intracranial pressure that results in excess catecholamine state and possibly CBN. A brain-heart link is more known to cardiologists than neurologists. This chapter provides some insight into the pathophysiology of these pathologic neurocardiac states and their most appropriate management relevant to neurologists.

The evaluation of myocardial function of patients in the early stage of acute ischemic stroke by two-dimensional speckle tracking echocardiography

PURPOSE

To evaluate the myocardial dysfunction in the early stage of nonhemorrhagic stroke and its association with the National Institutes of Health Stroke Scale (NIHSS) score, by two-dimensional speckle tracking echocardiography.

METHODS

We included 29 patients with acute ischemic stroke, in whom NIHSS scores were calculated and stroke infarct volumes recorded. Within 48 hours of admission, cardiac evaluation with speckle tracking echocardiography was performed and left ventricular global longitudinal strain (GLS) and global longitudinal systolic strain rate were obtained. These measurements were repeated on the 10th day.

RESULTS

NIHSS score improved, but infarct volume increased (p = 0.011 and 0.065, respectively) from admission to day 10. Ejection fraction was 53.2% and 55.8%, respectively, at admission and day 10 (p = 0.482), while GLS improved from -16.41% to -18.76% (p = 0.003).

CONCLUSIONS

GLS and global longitudinal systolic strain rate showed significant improvement together with NIHSS score. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:305-311, 2016.

Neurogenic stress cardiomyopathy associated with subarachnoid hemorrhage

Cardiac manifestations are recognized complications of subarachnoid hemorrhage. Neurogenic stress cardiomyopathy is one complication that is seen in acute subarachnoid hemorrhage. It can present as transient diffuse left ventricular dysfunction or as transient regional wall motion abnormalities. It occurs more frequently with neurologically severe-grade subarachnoid hemorrhage and is associated with increased morbidity and poor clinical outcomes. Managing this subset of patients is challenging. Early identification followed by a multidisciplinary team approach can potentially improve outcomes.

Neurogenic stunned myocardium associated with pediatric brain tumor may not be catecholamine-induced

A rare case of pediatric neurogenic stunned myocardium (NSM) associated with a brain tumor is reported. A previously healthy 6-year-old boy presented with coma, and imaging studies revealed a brain tumor. On hospitalization day 3, he developed NSM and neurogenic pulmonary edema necessitating intensive cardiopulmonary support. Although blood marker levels of cardiac injury were elevated, his plasma and urinary norepinephrine levels were within normal limits. His cardiorespiratory functions markedly improved by hospitalization day 8. This case report may be one of the first to document plasma and urinary catecholamine levels in pediatric NSM. While solid conclusion cannot be drawn based on experience from a single case, these results suggest that pediatric NSM may not be catecholamine-induced.

Neurogenic pulmonary edema in an infant with ventriculoperitoneal shunt malfunction

Neurogenic pulmonary edema (NPE) and neurogenic stunned myocardium are known complications of acute neuropathology, but these conditions have only rarely been reported with ventriculoperitoneal shunt malfunction. Furthermore, shunt malfunction presenting with NPE has not been described in a pediatric patient. A case of acute shunt malfunction and NPE followed by a complicated cardiopulmonary clinical course is reviewed.

Acute cardiac sympathetic disruption and left ventricular wall motion abnormality in takotsubo syndrome

Takotsubo syndrome (TS) is characterized by a unique pattern of transient circumferential left ventricular wall motion abnormality (LVWMA). The LVWMA in TS may be localized to the apical, mid-apical, mid-ventricular, mid-basal or basal regions of the left ventricle. Focal and generialized (global) LVWMA have also been reported. In the acute phase of TS, the hyperkinetic valve-like motion of the basal segments and/or the hyperkinetic slingshot-like motion of the apical segments combined with the firm stunned a-, hypokinetic segments result in a conspicuous left ventricular ballooning during systole. The LVWMA in TS follows most probably the local cardiac sympathetic nerve distribution and caused by local cardiac sympathetic disruption and noradrenaline spillover.

Sepsis-induced myocardial depression and takotsubo syndrome

Abstract Background and objectives: Myocardial depression in the setting of sepsis and septic shock is common and has been recognized for a long time. The aim of this study is to find out an association and causal link between sepsis and takotsubo syndrome (TS).

METHODS

Fifteen cases of TS were studied. Critical review of the literature dealing with sepsis and myocardial depression was done Results: Fifteen cases of sepsis-induced TS are described. Fifty-three per cent of the patients were men. The ages ranged from 39 to 76 years (mean age 60 years). Two-thirds of the patients had ST-elevation myocardial infarction ECG changes. Complications occurred in 80% of the patients. No specific types of sepsis or micro-organisms were associated with the development of TS. Critical review of the sepsis-induced myocardial depression shows that the left ventricular dysfunction, which is reversible within one-to-two weeks, is characterized by segmental ventricular dysfunction, and involvement of the right ventricle in one fourth of cases. These features are also consistent with TS.

CONCLUSIONS

Sepsis triggers TS, which may be the cause of the majority of cases of sepsis-induced myocardial depression. Acute cardiac sympathetic disruption with noradrenaline spill-over may be the cause of sepsis-induced TS.