Takotsubo Cardiomyopathy in Aneurysmal Subarachnoid Hemorrhage with an Atypical Clinical Presentation: A Case Report

Abstract

Takotsubo cardiomyopathy can masquerade as an acute coronary syndrome and present clinically with chest pain and dyspnea, electrocardiogram changes of cardiac ischemia and elevation of cardiac enzymes. Such changes are particularly relevant in cases where Takotsubo cardiomyopathy is associated with subarachnoid hemorrhage, and treatment of acute coronary syndrome with antiplatelet drugs is contraindicated. We describe a case of a 68-year-old woman, who developed ventricular changes consistent with Takotsubo cardiomyopathy following an aneurysmal subarachnoid hemorrhage. The patient presented with collapse and vomiting, initial workup revealed anterior ST-elevation electrocardiogram changes, increased troponin I, and a chest radiograph suggestive of acute cardiac failure. In light of this, the patient was managed initially as an acute coronary syndrome with antiplatelet medication. An echocardiogram showed acute left ventricular systolic dysfunction with apical ballooning. After 3 days of hospitalization, she became increasingly drowsy with a worsening headache. Computed tomography of the head revealed intracerebral hemorrhage and bilateral subarachnoid hemorrhage and computed tomography angiography demonstrated a 9 × 5 mm A2 aneurysm. She subsequently underwent embolization to treat the ruptured aneurysm. She recovered well neurologically, and subsequent cardiac imaging revealed a complete resolution of her prior issues.