Neurology India Medknow Publications on behalf of the Neurological Society of India ISSN: 0028-3886 EISSN: 1998-4022 Vol. 59, Num. 3, 2011, pp. 480-482

Neurology India, Vol. 59, No. 3, May-June, 2011, pp. 480-482

Letter to Editor

Tako-Tsubo syndrome following status epilepticus

S Traullé¹, M Kubala¹, G Jarry², L Leborgne², JS Hermida¹

¹ Rhythmology Center, University Hospital of Amiens, Laennec Avenue 80054 Cedex 1, Amiens, France
² Cardiologic Intensive Care Unit, University Hospital of Amiens, Amiens, France

Correspondence Address: S TraulléRhythmology Center, University Hospital of Amiens, Laennec Avenue 80054 Cedex 1, Amiens France traulle.sarah@chu-amiens.fr

Code Number: ni11143

PMID: 21743196

DOI: 10.4103/0028-3886.82759

Sir,

Tako-Tsubo syndrome is a cardiomyopathy characterized by transient myocardial dysfunction affecting left ventricular apex and occurs in the setting of physical or emotional stress. We describe occurrence of Tako-Tsubo syndrome in a patient with status epilepticus (SE).

A 50-year-old man developed frontal syndrome with right facial palsy following a traumatic brain injury in a road-traffic accident. He was admitted into intensive care unit for SE and was intubated and on mechanical ventilation. He developed hemodynamic instablity associated with left heart failure requiring the use of dobutamine and diuretics. Electrocardiogram (ECG) showed a lateral ST segment elevation. Troponin levels were elevated, 25 μg/l (Normal range <0.14 μg/l) and also serum CPK levels, 1269 UI/l, (Normal range <239 UI/l). The echocardiogram revealed a left ventricular ejection fraction of 35% and a ballooning because of apical akinesia and hypercontractility of the basal portions. Cardiac catheterization showed coronary arteries free of significant atherosclerotic lesions. The ventriculography confirmed left ventricular apical ballooning [Figure - 1]. His condition improved rapidly, there was gradual recovery of left ventricular function and normalization of cardiac enzyme was observed over a few days.

Tako Tsubo syndrome, also called "transient left ventricular apical ballooning" was described in 1990 by Sato. This syndrome refers to the end-systolic appearance of the left ventricle on ventriculography and its resemblance to the amphora used to catch octopuses (tako: Octopus, tsubo: Trap). ^[1] The prevalence of this syndrome remains unknown. It represented approximately 2.2% of acute coronary syndromes with ST segment elevation treated between 2002 and 2003 in the Mayo Clinic. ^[2] Unlike our patient, there is a strong female predominance especially among postmenopausal women, 82-100% with the average age between 62 and 75 years. ^[2] Abe and Kondo have proposed the diagnostic criteria. ^[3] The major criteria are the left ventricular apical ballooning in addition to hypercontraction of the basal segments with reversible evolution, changes in the ST segment and T-wave on ECG. In most cases a context of physical or emotional stress, moderate elevation of cardiac enzyme and chest pain are associated.This syndrome mimics myocardial infarction in terms of clinical, biological and ECG characteristics. The absence of significant coronary stenosis on coronary angiography should suggest the diagnosis and left ventricular angiography should be done. The classical ECG evolution is characterized by resolution of the ST-segment elevation, a possible QT prolongation and development of diffuse and often deep T-waves inversion, which may persist for several weeks [Figure - 2]. Various studies consistently reported the discrepancy between the slight elevation of troponin and the extent of myocardial dysfunction. This is a sideration of the heart muscle and not necrosis with reversible abnormalities. Catecholamine excess triggered by emotional or physical stress is proposed as the major underlying mechanism in the pathogenesis of this phenomenon. ^[4] Catecholamine surge has been shown to occur during SE. ^[5] Tako-Tsubo syndrome has generally a favorable prognosis because of the recovery of a normal contractility after a few days to several weeks. ^[2]

It is important to recognize that patients with SE may have a risk of catecholamine surge which can induced myocardial dysfunction. Some specific factors could explain the difficulties of recognizing Tako-Tsubo syndrome in patients with SE: inability to complain chest discomfort in the presence of altered mental state and CPK elevation as result of convulsive seizures. But knowing this cardiac entity should help the physician to recognize ECG changes, understand hemodynamic instability and left heart failure that could occur during SE.

References

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