Takotsubo Cardiomyopathy and Intra-Cardiac Thrombus Complicating Cerebellar Haemorrhage

Abstract

An 86-year-old female with background of hypertension and mild Alzheimer's was found with dysarthria, nausea and vomiting. She was haemodynamically stable without chest pain or dyspnoea. Computed tomography of her brain revealed right cerebellar haemorrhage. ECG showed anterolateral ST elevation; not initially addressed perhaps due to lack of cardiac symptoms and more pressing haemorrhage. Three days later she developed heart failure. Elevated troponin and transthoracic echocardiogram (TTE) were consistent with Takotsubo cardiomyopathy (TTC) but also revealed left ventricular apical intra-cardiac thrombus (ICT). Intracranial events are well reported triggers of TTC, most commonly subarachnoid haemorrhages. Intracerebral haemorrhages (ICH) are less common, though interestingly of nine reported ICH triggered-TTC, four were cerebellar haemorrhages, suggesting an increased risk with this location. ICT occurs in 2.5-8% of TTC patients, with cardio-embolic events occurring in 12.2% of these, similar to rates following myocardial infarction (MI). Risk factors for ICT following TTC include apical variant, presence of ST elevation on ECG, and elevated CRP–all seen in this patient. Evidence for management of ICT in TTC is scant. Indirect data from MI-related ICT suggest benefit in oral anticoagulation for preventing ICT and reducing rates of embolisation. Of course, with recent ICH and risk of future ICH due to presumed amyloid angiopathy, anticoagulation was contraindicated here. This is an unfortunate situation with limited recourse other than to monitor left ventricular recovery and thrombus resolution. In absence of bleeding, more research into early anticoagulation for prevention of ICT in TTC in high-risk patients is warranted.