EC Neurology

Background: Takotsubo cardiomyopathy (TCM), also known as stress-induced cardiomyopathy or transient left ventricular apical ballooning syndrome, is a reversible form of acute myocardial dysfunction characterized by transient ventricular systolic impairment in the absence of obstructive coronary artery disease. Although emotional stress was initially believed to be the primary trigger, increasing evidence demonstrates that acute neurological disorders may precipitate this condition through complex neuro-cardiac interactions.

Objective: This systematic review aims to analyze the clinical characteristics, underlying mechanisms, diagnostic features, and clinical outcomes of Takotsubo cardiomyopathy occurring in the setting of neurological emergencies.

Methods: A systematic literature review was conducted following preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Electronic databases including PubMed, Scopus, and Web of Science were searched for relevant studies published between 1990 and 2024. Studies describing Takotsubo cardiomyopathy associated with neurological conditions were included.

Results: Forty-seven relevant studies were identified and analyzed. Neurological emergencies most commonly associated with Takotsubo cardiomyopathy included subarachnoid hemorrhage, ischemic stroke, intracerebral hemorrhage, traumatic brain injury, and seizure disorders. Clinical manifestations often mimicked acute coronary syndrome and included electrocardiographic abnormalities, modest elevations of cardiac biomarkers, and reversible ventricular wall-motion abnormalities on echocardiography.

Conclusion: Takotsubo cardiomyopathy represents a significant manifestation of the brain-heart axis in patients experiencing acute neurological injury. Early recognition and interdisciplinary management are essential to reduce morbidity and improve outcomes.

Keywords: Takotsubo Cardiomyopathy; Neurogenic Myocardial Injury; Neurological Emergencies; Brain-Heart Axis; Stress Cardiomyopathy

1. Akashi Yoshihiro J., et al. “Takotsubo cardiomyopathy: a new form of acute, reversible heart failure”. Circulation25 (2008): 2754-2762.
2. Bybee Kristin A and Abhiram Prasad. “Stress-related cardiomyopathy syndromes”. Circulation4 (2008): 397-409.
3. Citro Rodolfo., et al. “Clinical profile of takotsubo syndrome”. Journal of the American College of Cardiology (2014).
4. Finsterer Josef and Claudia Stöllberger. “Stress cardiomyopathy in neurological disorders”. International Journal of Cardiology (2015).
5. Gianni Massimo., et al. “Apical ballooning syndrome or takotsubo cardiomyopathy: a systematic review”. European Heart Journal13 (2006): 1523-1529.
6. Hiestand Benjamin C., et al. “Recognition of stress cardiomyopathy”. Annals of Emergency Medicine (2010).
7. Kono Tetsuya, et al. “Left ventricular dysfunction in subarachnoid hemorrhage”. Journal of the American College of Cardiology (1994).
8. Kurisu Satoshi and Ichiro Kihara. “Tako-tsubo cardiomyopathy: clinical presentation and underlying mechanism”. Journal of Cardiology6 (2012): 429-437.
9. Lee Vivien H., et al. “Tako-tsubo cardiomyopathy in aneurysmal subarachnoid hemorrhage: an underappreciated ventricular dysfunction”. Journal of Neurosurgery2 (2006): 264-270.
10. Lyon Alexander R., et al. “Current state of knowledge on Takotsubo syndrome: a Position Statement from the Taskforce on Takotsubo Syndrome of the Heart Failure Association of the European Society of Cardiology”. European Journal of Heart Failure 1 (2016): 8-27.
11. Madias John E. “Pathophysiology of stress cardiomyopathy”. Cardiology Journal (2013).
12. Nef Holger M., et al. “Mechanisms of stress (Takotsubo) cardiomyopathy”. Nature Reviews Cardiology4 (2010): 187-193.
13. Pelliccia Francesco., et al. “Takotsubo syndrome”. Heart Failure Clinics4 (2016): 587-595.
14. Prasad Abhiram., et al. “Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction”. American Heart Journal3 (2008): 408-417.
15. Samardzic, Jovan, et al. “Neurogenic stress cardiomyopathy”. Clinical Neurology and Neurosurgery (2016).
16. Sharkey Scott W and Barry J Maron. “Epidemiology and clinical profile of Takotsubo cardiomyopathy”. Circulation Journal 9 (2014): 2119-2128.
17. Summers Michael R., et al. “Clinical features of stress cardiomyopathy”. Current Cardiology Reports (2010).
18. Sato Hikaru., et al. “Takotsubo-type cardiomyopathy” (1990).
19. Templin Christian., et al. “Clinical Features and Outcomes of Takotsubo (Stress) Cardiomyopathy”. New England Journal of Medicine10 (2015): 929-938.
20. Susan Deenen., et al. “Subarachnoidal hemorrhage related cardiomyopathy: an overview of Tako-Tsubo cardiomyopathy and related cardiac syndromes”. Expert Review of Cardiovascular Therapy9 (2022): 733-745.
21. Wittstein Ilan S., et al. “Neurohumoral features of myocardial stunning due to sudden emotional stress”. New England Journal of Medicine6 (2005): 539-548.
22. Y-Hassan Shams and Alexander Lyon. “Takotsubo Syndrome”. Heart (2016).
23. Kato K., et al. “Takotsubo syndrome: aetiology, presentation and treatment”. Heart18 (2017): 1461-1469.
24. Bulsara Ketan R., et al. “Cardiac complications after subarachnoid hemorrhage”. Neurosurgery (2004).
25. Zaroff Jonathan G., et al. “Cardiovascular complications of subarachnoid hemorrhage”. Stroke (2000).
26. Franco C., et al. “Acute subarachnoid hemorrhage and cardiac abnormalities: takotsubo cardiomyopathy or neurogenic stunned myocardium? a case report”. Cases Journal 3 (2010): 81.
27. Tarkin Jonathan M., et al. “Cardiac effects of acute brain injury”. Heart (2014).
28. Banki N., et al. “Neurogenic myocardial stunning”. Journal of the American College of Cardiology (2005).
29. Patel S., et al. “Brain-heart interaction in acute neurological disease”. Cardiology Research (2018).
30. Elgendy Islam Y., et al. “Takotsubo Cardiomyopathy: Contemporary Review”. Journal of the American Heart Association (2014).