Tako-tsubo cardiomyopathy in aneurysmal subarachnoid hemorrhage: an underappreciated ventricular dysfunction

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Neurogenic stunned myocardium in aneurysmal subarachnoid hemorrhage (SAH) is associated with a wide spectrum of reversible left ventricular wall motion abnormalities and includes a subset of patients with a pattern of apical akinesia and concomitant sparing of basal segments called “tako-tsubo cardiomyopathy.”


After obtaining institutional review board approval, the authors retrospectively identified among all patients admitted to the Mayo Clinic’s Neurological Intensive Care Unit between January 1990 and January 2005 those with aneurysmal SAH who had met the echocardiographic criteria for tako-tsubo cardiomyopathy. Among 24 patients with SAH-induced reversible cardiac dysfunction, the authors identified eight with SAH-induced tako-tsubo cardiomyopathy. All eight patients were women with a mean age of 55.5 years (range 38.6–71.1). Seven patients presented with a poor-grade SAH, reflected by a Hunt and Hess grade of III or IV. Four patients underwent aneurysm clip application, and four underwent endovascular coil occlusion. The initial mean ejection fraction (EF) was 38% (range 25–55%), and the mean EF at recovery was 55% (range 40–68%). Cerebral vasospasm developed in six patients, but cerebral infarction developed in only three patients.


The authors describe the largest cohort with aneurysmal SAH–induced tako-tsubo cardiomyopathy. In the SAH population, tako-tsubo cardiomyopathy predominates in postmenopausal women and is often associated with pulmonary edema, prolonged intubation, and cerebral vasospasm. Additional studies are warranted to understand the complex mechanism involved in tako-tsubo cardiomyopathy and its intriguing relationship to neurogenic stunned myocardium.

Abbreviations used in this paper:CK-MB = creatine kinase MB isoenzyme;; CT = computed tomography;; ECG = electrocardiography;; EF = ejection fraction;; LV = left ventricular;; NICU = neurological intensive care unit;; SAH = subarachnoid hemorrhage.

Article Information

Address reprint requests to: Eelco F. M. Wijdicks, M.D., Department of Neurology, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, Minnesota 55905. email: wijde@mayo.edu.

© AANS, except where prohibited by US copyright law.



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    Photograph illustrating a tako-tsubo, a Japanese octopus catcher pot, which is strung by rope from Japanese fishing boats. Anachoresis (living in crevices and holes) is typical behavior of octopuses. Photograph by Sarah H. Lee.

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    Illustration of the heart depicting a normal (left) and abnormal (right) cardiac contraction. After aneurysmal SAH, the cardiac contraction becomes abnormal, with apical and midventricle akinesia consistent with tako-tsubo cardiomyopathy.

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    Schematic demonstrating initial echocardiographic regional wall motion abnormalities. Note the preferential involvement of apical and midventricle segments. From left to right, the segments shown are base, middle, and apex.

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    Graph showing the initial and final EFs in SAH-induced tako-tsubo cardiomyopathy.


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