Severe and Atypical Presentation of Takotsubo Cardiomyopathy in a Pediatric Patient after a Serious Crash Injury-Case Report and Literature Review

Abstract

Takotsubo cardiomyopathy is an uncommon clinical entity in children, resulting in severe but sometimes reversible systolic dysfunction of the left ventricle. This condition is triggered by multiple emotional or physical stressors, while neurogenic stress cardiomyopathy after brain injuries has become increasingly recognized in children over the past few years. We report the case of an 11-year-old child with an atypical clinical presentation after a serious car crash accident. An initial computed tomography scan revealed an acute epidural hematoma, which was immediately treated by an emergency craniotomy. During the patient's following pediatric intensive care unit hospitalization, severe hemodynamic instability was observed, leading to gradually higher doses of vasopressors for circulatory support. On echocardiography, the patient had signs of severe cardiac contractility compromise, with characteristic pattern of regional wall motion abnormalities of the left ventricle, which, in combination with seriously elevated cardiac enzymes, electrocardiographic (ECG) abnormalities and continuous thermodilution hemodynamic monitoring (PICCO) findings, led to intensification of inotropic support and to the diagnosis of takotsubo cardiomyopathy. Despite supportive measures, the patient developed multiorgan failure and succumbed to their serious illness. For this atypical case, extracorporeal membrane oxygenation (ECMO) was addressed as an option for the seriously failing heart, but due to the extremely high risk of intracranial bleeding, it could not be used for this patient's treatment. In conclusion, Takotsubo cardiomyopathy should be suspected in pediatric cases of cardiac dysfunction after serious injuries or stress conditions.

Keywords: epidural hematoma; takotsubo cardiomyopathy; traumatic brain injury.

Figure 1

Brain Computed Tomography (CT) scan within 2 h of the accidentshowing: (a) acute left temporal and parietal epidural hematoma (arrow) (5 × 8 cm) with (b) mass effect and 4 mm midline shift (arrow), (c) Bone window of head CT scan showing a complex nondisplaced comminuted fracture of the left temporal bone (arrow), and (d) Chest CT showing contusions of the right upper lobe (arrow), right middle lobe and lower left lobe of the lungs (GE Healthcare Revolution 128-slice CT scanner, USA—Slice thickness of 1.25–5 mm with 3D Reconstructions).

Figure 2

Echocardiography showing a severe compromise of cardiac contractility with regional wall motion abnormalities (thin arrows), apical hyperkinesia (thick arrow), along with reduced left ventricular ejection fraction (EF) of 40%, and fractional shortening (FS) of 28%. At end-systole the left ventricle resembles the basal ballooning pattern, giving the appearance of reverse Takotsubo cardiomyopathy (Video Recording of the Echocardiography: https://doi.org/10.6084/m9.figshare.20526903).