Takotsubo cardiomyopathy in a 12-year-old boy caused by acute brainstem bleeding-a case report

Abstract

Takotsubo cardiomyopathy is characterized by acute and reversible severe left ventricular dysfunction due to intensive emotional or physical stress followed by catecholamine excess. Traditionally it is most common in postmenopausal women, whereas only few cases have been described in childhood. In our case a previously well 12-year-old boy presented with severe cardiogenic shock due to dramatically impaired left ventricular function requiring significant inotropic support and invasive mechanical ventilation. Interestingly, cardiac catheterization, myocardial tissue histology and biochemical laboratory tests did not yield a definitive diagnosis. As his cardiac function improved gradually within several days and deep sedation could be weaned, he was then found to suffer from hemiparesis and absence of protective airway reflexes on neurological examination during the weaning process. Subsequent brain imaging studies revealed a brainstem bleeding due to a fistulous arteriovenous malformation (AVM) appearing to be only a few days old. After endovascular coiling and subsequent microsurgical resection of the malformation, he recovered completely. Our present case demonstrated, that brainstem bleeding could precipitate Takotsubo cardiomyopathy manifesting hemodynamic collapse. Severe ventricular impairment has been described in many adults with subarachnoid hemorrhage; however, this condition is extremely rare among children. When severe cardiogenic shock is diagnosed, precipitating factors such as intracranial processes should be ruled out on a regular basis.

Keywords: Takotsubo cardiomyopathy; case report; child; intracranial hemorrhage; stress-cardiomyopathy.

Figure 1

Emergency echocardiography of a 12-year-old boy with Takotsubo cardiomyopathy caused by acute brainstem bleeding showing (A) LV dilatation and (B) MI III°. LV, left ventricle; MI, mitral insufficiency.

Figure 2

Diagnostic findings in a 12-year-old boy with Takotsubo cardiomyopathy caused by acute brainstem bleeding showing (A) ECG with tachycardic sinus rhythm (140 bpm) with ST-depressions in II, III, aVF and elevations in V1–4 (red circles) and (B) highly elevated cardiac enzymes which nearly normalized after 1 week. ECG, electrocardiogram; aVF, augmented voltage foot; NT-proBNP, NT-pro brain natriuretic peptide.

Figure 3

Initial chest X-ray of a 12-year-old boy with Takotsubo cardiomyopathy caused by acute brainstem bleeding after intubation and placement of a central line in the ED, showing pulmonary oedema. ED, emergency department.

Figure 4

Cerebral imaging in a 12-year-old boy with Takotsubo cardiomyopathy caused by (A) hematoma close to the dorsocaudal medulla oblongata (red arrow left image) with intraventricular blood accumulation in the lateral ventricles (red arrows right image) based on (B) a fistulous AVM (red circles) adjacent to the medulla oblongata. AVM, arteriovenous malformation.

Figure 5

Intraoperative images of a 12-year-old boy with Takotsubo cardiomyopathy caused by acute brainstem bleeding showing (A) the fistulous AVM on the dorsal medulla oblongata and (B) the postoperative status with complete resection of the fistulous AVM. AVM, arteriovenous malformation.