Two pediatric cases of variant neurogenic stress cardiomyopathy after intracranial hemorrhage

Takotsubo cardiomyopathy, also known as stress-induced cardiomyopathy, is an acquired form of left ventricular systolic dysfunction seen in the setting of physiologic stress and the absence of coronary artery disease. It is thought to be caused by excessive sympathetic stimulation. It is well described in the adult literature associated with subarachnoid hemorrhage where it is known as neurogenic stress cardiomyopathy (NSC), but few such pediatric cases have been reported. We describe our experience with 2 children (13- and 10-year-old girls) who presented with spontaneous intracranial hemorrhage followed by pulmonary edema and shock. Echocardiography revealed similar patterns of left ventricular wall motion abnormalities consistent with NSC, inverted Takotsubo variant. One child progressed to death, whereas the other made a remarkable recovery, including significant improvement in cardiac function over the course of 1 week. We argue that at least 1 of these cases represents true stress-induced cardiomyopathy. This report will alert pediatricians to this transient cardiomyopathy that is likely underdiagnosed in pediatric intensive care. We also highlight the challenges of managing both shock and elevated intracranial pressure in the setting of NSC.

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.

Fragile Endothelium and Brain Dysregulated Neurochemical Activity in COVID-19

Immune system and renin-angiotensin-aldosterone system dysregulation with associated cytokine release syndrome may be a key feature of early stage of SARS-CoV-2 organotropism and infection. Following viral mediated brain injury, dysregulated neurochemical activity may cause neurogenic stress cardiomyopathy, which is characterized by transient myocardial dysfunction and arrhythmias. Cardiomyopathy along with acute acute inflammatory thromboembolism and endotheliitis (fragile endothelium) might at least partially explain the underlying mechanisms of rapidly evolving life-threatening COVID-19. Further studies are clearly required to explore these complex pathologies.

Reversible Stress Cardiomyopathy Secondary to Aneurysmal Subarachnoid Hemorrhage: A Case Report

BACKGROUND

Acute cerebral incidents have been correlated with cardiac manifestations. Specifically, subarachnoid hemorrhage has been correlated with a syndrome described as neurogenic stress cardiomyopathy and mimics acute coronary syndrome.

CASE REPORT

A 55-year-old woman presented at the Emergency Department of our hospital complaining of vomiting and headache of sudden onset. Computed tomography angiography revealed a ruptured aneurysm at the tip of the basilar artery and the patient underwent a successful complete embolism of the sac of the aneurysm. During hospitalization, the patient developed electrocardiographic alterations and elevation of cardiac biomarkers, and echocardiography showed an impairment of left ventricular systolic function. The patient was diagnosed with neurogenic stress cardiomyopathy and she was treated conservatively. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Clinicians should be aware of neurogenic stress cardiomyopathy because early diagnosis and treatment are the cornerstones for achieving a better outcome.

Prospective Analysis of Role of hsTnT and NT-proBNP in Prediction of Neurogenic Stress Cardiomyopathy in Patients with Aneurysmal Subarachnoid Haemorrhage

Background

Neurogenic stress cardiomyopathy (NSC), also known as stress-induced cardiomyopathy (SIC), is a significant complication of aneurysmal subarachnoid hemorrhage and an important contributor to morbidity mortality.

Objective

This prospective observational study assessed whether the high sensitive troponin T (hsTnT) and N-terminal pro-B-type natriuretic peptide (NTproBNP) helps in the prediction of NSC after SAH.

Methods

The consecutive patients with aSAH without any cardiac history were included prospectively over 12 months. Neurological assessment for the grade of SAH (Hunt & Hess and WFNS grade), electrocardiogram, and echocardiography done at admission. The serial measurements of serum hsTnT and NTproBNP for consecutive 7 days done. The NSC is defined as transient hypokinesia of the ventricular wall on echocardiography.

Results

The study included 69 patients, and 7 (10.1%) were diagnosed with NSC. The NSC had a positive correlation with Hunt and Hess grade (P = 0.010), and the serum levels of hsTnT and NTproBNP were higher in patients with NSC in comparison to without NSC over all 7 days. The peak levels of hsTnT and NTproBNP were significantly higher in patients with cardiomyopathy (P = 0.000 and 0.032, respectively). The best cut-off level of peak hsTnT was 0.032 pg/dl to predict cardiomyopathy with sensitivity and specificity of 100% and 80%, respectively, and NTproBNP was 430.6 ng/dL with sensitivity and specificity of 86% and 73%, respectively.

Conclusion

The peak levels of hsTnT and NTproBNP with abnormal ECG and echocardiography at admission help identify NSC in the early phase of aSAH.

Prevalence of neurogenic stress cardiomyopathy in acute ischemic stroke and relationship with leukocytosis

OBJECTIVE

Describe the prevalence and features of neurogenic stress cardiomyopathy in acute ischemic stroke. Describe leukocytosis as an inflammatory marker in neurogenic stress cardiomyopathy.

MATERIALS/METHODS

Retrospective review of 688 adult ischemic stroke patients at a tertiary care center (1/2018 - 12/2021). Neurogenic stress cardiomyopathy was identified by one of: low left ventricular ejection fraction, ventricular wall motion abnormalities, elevated Troponin-I, or elevated brain natriuretic peptide. Leukocytosis defined as white blood cell count ≥12.0 × 10^9/L. Clinical and demographic data were collected.

RESULTS

Neurogenic stress cardiomyopathy was observed in 147 (21 %) patients. In this group, mean age was 68, 44 % were female, mean National Institutes of Health Stroke Scale was 10 and mean hospital stay was 8 days. Low left ventricular ejection fraction (median 40 %) was observed in 64 % of these patients, elevated Troponin-I (median 0.252 ng/mL) in 40 %, and ventricular wall motion abnormalities in 55 %. Stroke mechanisms were cryptogenic (43 %), cardioembolic (24 %), small vessel disease (13 %), large artery atherosclerosis (12 %), and other (8 %). Mean white blood cell count was 8.63 × 10^9/L. Leukocytosis occurred in 12 % of patients with cardiomyopathy and 8 % without, with no significant difference (p=0.9).

CONCLUSION

We propose defining neurogenic stress cardiomyopathy by one of four cardiac biomarkers. The prevalence aligns with prior reports, most frequently identified by low left ventricular ejection fraction or ventricular wall motion abnormalities. Unlike Takotsubo Cardiomyopathy, abnormal wall motion patterns were predominantly diffuse. No significant difference in leukocytosis was found between groups. Further research is needed to identify neurogenic stress cardiomyopathy risk factors.

The Hidden Heart: Exploring Cardiac Damage Post-Stroke: A Narrative Review

Stroke-heart syndrome (SHS), a critical yet underrecognized condition, encompasses a range of cardiac complications that arise following an ischemic stroke. This narrative review explores the pathophysiology, clinical manifestations, and implications of SHS, focusing on the complex interplay between the brain and the heart. Acute ischemic stroke (AIS) triggers autonomic dysfunction, leading to a surge in catecholamines and subsequent myocardial injury. Our review highlights the five cardinal manifestations of SHS: elevated cardiac troponin (cTn) levels, acute myocardial infarction, left ventricular dysfunction, arrhythmias, and sudden cardiac death. Despite the significant impact of these complications on patient outcomes, there is a notable absence of specific guidelines for their management. Through a comprehensive literature search, we synthesized findings from recent studies to elucidate the mechanisms underlying SHS and identified gaps in the current understanding. Our findings underscore the importance of early detection and multidisciplinary management of cardiac complications post-stroke. Future research should focus on establishing evidence-based protocols to improve clinical outcomes for stroke patients with SHS. Addressing this unmet need will enhance the care of stroke survivors and reduce mortality rates associated with cardiac complications.