Early endovascular treatment of aneurysmal subarachnoid hemorrhage complicated by neurogenic pulmonary edema and Takotsubo-like cardiomyopathy

Abstract

Aneurysmal subarachnoid hemorrhage (SAH) may be associated with acute cardiopulmonary complications, like neurogenic pulmonary edema (NPE) and Takotsubo-like cardiomyopathy (TCM). These dysfunctions seem to result from a neurogenically induced overstimulation of the sympathetic nervous system through the brain-heart connection and often complicate poor grade aneurysmal SAH. The optimal treatment modality and timing of intervention in this clinical setting have not been established yet. Early endovascular therapy seems to be the fitting treatment in this particular group of patients, in which surgical clipping is often contraindicated due to the added risk of craniotomy. Herein we describe the case of a woman admitted to the emergency department with aneurysmal SAH complicated by NPE-TCM, in which early endovascular coiling was successfully performed. Our case, characterized by a favorable outcome, further supports the evidence that early endovascular treatment should be preferred in this peculiar clinical scenario.

Keywords: Takotsubo cardiomyopathy; aneurysmal subarachnoid hemorrhage; endovascular treatment; neurogenic pulmonary edema.

Figure 1

Unenhanced brain CT shows SAH involving the interhemispheric fissure and right sylvian fissure; hemorrhage into the left lateral ventricle is associated.

Figure 2

CT angiogram demonstrates an aneurysm (maximum diameter: 6 mm, neck: 3 mm) of the M1 segment of the right middle cerebral artery.

Figure 3

Left ventriculography reveals the ampulla-shaped morphology of the left ventricle, a characteristic sign of Takotsubo-like cardiomyopathy.

Figure 4

Digital subtraction angiography (DSA) (oblique projection) confirms the aneurysm of the right M1, well demonstrating its size, orientation and neck.

Figure 5

DSA (same projection) testifies the success of the embolizing procedure, showing complete obliteration of the lumen of the aneurysm by detachable coils.