A case report of takotsubo syndrome complicated by ischaemic stroke: the clinical dilemma of anticoagulation

Giuseppe Iuliano; Rosa Napoletano; Carmine Vecchione; Rodolfo Citro

doi:10.1093/ehjcr/ytab051

A case report of takotsubo syndrome complicated by ischaemic stroke: the clinical dilemma of anticoagulation

Eur Heart J Case Rep. 2021 Mar 15;5(3):ytab051. doi: 10.1093/ehjcr/ytab051. eCollection 2021 Mar.

Authors

Giuseppe Iuliano¹, Rosa Napoletano², Carmine Vecchione^{1

3}, Rodolfo Citro¹

Affiliations

¹ Cardiothoracic and Vascular Department, Cardiology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Heart Tower-Room 807, Largo Città d'Ippocrate, 84131 Salerno, Italy.
² Neurology Department, Stroke Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Largo Città d'Ippocrate, 84131 Salerno, Italy.
³ Vascular Pathophysiology Unit, IRCCS Neuromed, Via Atinense, 18, 86077 Pozzilli, Isernia, Italy.

Abstract

Background: Takotsubo syndrome (TTS) is an acute and transient heart failure syndrome due to reversible myocardial dysfunction characterized by a wide spectrum of possible clinical scenarios. About one-fifth of TTS patients experience adverse in-hospital events. Thromboembolic complications, especially stroke, have been reported, albeit in a minority of patients.

Case summary: A 69-year-old woman presented to our emergency department for dyspnoea after a family quarrel. Electrocardiogram revealed ST-segment elevation in anterolateral leads and laboratory exams showed a slight elevation of high-sensitivity cardiac troponin. The patient was treated according to current guidelines on ST-elevation myocardial infarction and referred to the cath lab. Urgent coronary angiography revealed normal coronary arteries. Based on the patient profile and instrumental findings, a diagnosis of TTS was hypothesized. After 6 days, the patient developed dysarthria and right hemiparesis under therapy with aspirin, whilst low molecular weight heparin had been previously withdrawn. Transthoracic echocardiography (TTE) revealed persisting apical akinesia and a subtle intraventricular thrombus. Head computed tomography and magnetic resonance imaging detected focal areas of ischaemic necrosis resembling diffuse cardioembolic lesions. Anticoagulation therapy was started and regular TTE showed complete recovery of myocardial systolic function and absence of ventricular thrombi at 1-month follow-up. The patient fully recovered speech after 5 months.

Discussion: This challenging case reinforces current recommendations to administer antithrombotic therapy in TTS patients with extensive apical dysfunction up to complete or near-complete recovery of myocardial contractility, regardless of the presence of atrial fibrillation, and highlights the importance of close TTE monitoring during the acute phase.

Keywords: Cardioembolism; Case report; Intraventricular thrombosis; Ischaemic stroke; Takotsubo syndrome.

Publication types

Case Reports