Reverse takotsubo cardiomyopathy may be a bad prognostication sign following traumatic brain injury
CCCF ePoster library. FAQIHI F. Oct 3, 2017; 198222; 58
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Reverse takotsubo cardiomyopathy may be a bad prognostication sign following traumatic brain injury

Fahad Faqihi1, Shahzad Ahmad Mumtaz1, Abdullah Balhamar1, Saima Akhtar1,Ahmed Balshi1,  Mahmood Nasir Nasim1, Salem Bawazeer1, Ahmad Fouad Mady1, Abdulrahman Alharthy1, Ibrahim Soliman1, Peter Brindley2, Dimitrios Karakitsos1,3

1 ICU Department, King Saud Medical City, Riyadh, KSA, 2 ICU Department, University of Alberta, Edmonton, Canada, 3 ICU Department, Keck Medical School, USC, LA, CA, USA


Introduction: Neurogenic stress cardiomyopathy, also called Neurogenic stunned myocardium (NSM), is a syndrome occurs after severe acute brain injury due to catecholamine-mediated direct myocardial injury and dysfunction with ST changes and troponin leak. NSM includes different patterns of global or regional LV wall motion abnormalities which don’t match typical coronary artery distribution. In some patients LV kinetic abnormalities involve the apical region as in Takotsubo syndrome, while in others NSM has a pattern of “apical sparing” or reverse Takotsubo with contraction abnormalities in the basal and mid-ventricular portions of the LV wall with no involvement of the apex probably because of the paucity of sympathetic nerve terminals in the apex.
Objectives: To outline the echocardiographic patterns of neurogenic stunned myocardium (NSM) following traumatic brain injury (TBI). Only trauma patients with isolated severe [Glasgow Coma Scale (GCS) ≤ 8)] TBI were included.
Methods: Fourteen patients were admitted to our intensive care unit (ICU) with severe isolated TBI as their primary diagnosis. All were sedated, mechanically ventilated, and followed by the neurosurgery team. Patients received a daily echocardiography that focused on possible left ventricular (LV) abnormalities.  The study was approved by our Institutional Ethics and Research Committee.

Table 1. General and echocardiographic features of the study population

Table attached

12/14 patients received transthoracic echocardiograms (TTE); 2/14 patients received transesophageal echocardiography (TEE) because TTE images were of insufficient quality (Figure 1).
Figure. 1 Mid-esophageal TEE view depicting left ventricular basal segment hypokinesia and eccentric mitral valve regurgitation in isolated TBI.
The most common single (10/14; 71.4%) echocardiographic pattern resembled reverse takotsubo cardiomyopathy: preservation of apical systolic function plus moderate to severe eccentric mitral valve regurgitation. Follow-up demonstrated normalization of cardiac function in only 2/10 patients who presented with this pattern; whilst the other 4 cases showed normal cardiac function on follow-up examinations. 
Discussion:  In this small cohort, we observed an echocardiographic pattern resembling reverse takotsubo cardiomyopathy in 71.4% of cases. Four patients out of fourteen progressed towards brain death; thus this might be associated with poor prognosis. Larger prospective studies are required to explore this more thoroughly.                                                                                                                      
Conclusion: Following TBI, the presence of a reverse takotsubo cardiomyopathy might be associated with poor prognosis.

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