CONGRESS ABSTRACT

We describe a case of a 77-year-old patient admitted to the Emergency department for sudden onset of headache, loss of consciousness with deviation of the buccal commissure and repeated vomiting. She was previously treated for breast cancer and her only known cardiovascular risk factor was hypercholesterolemia, currently managed with a rosuvastatine/ezetimibe combination. A CT scan detected a right frontal cerebral  mass with perilesional oedema and the patient was transferred to the Neurosurgery department with a diagnosis of likely meningioma. The pre-operative ECG showed a sinus rhythm, a V3-V6 ST-segment depression and a slight QTc prolongation; she promptly underwent a transthoracic echocardiography (ETT), which highlighted an akinesia of all the mid left ventricular segments, with compensatory hyperkinesia of the apex and the basal segments; EF was moderately reduced (40-45%). An HS troponin elevation was detected. A coronary angiography was performed showing no obstructive coronary artery disease, while the ventriculography was consistent with a diagnosis of mid-ventricular Takotsubo cardiomyopathy. Neurosurgical treatment was momentarily delayed. The patient was started on oral Bisoprolol and Valsartan and had an uneventful clinical course during the hospital stay. At the discharge time, EF was 55% and residual hypokinesia of the mid-apical inferior and anterior septum was still present. Psychophysical rest was recommended to the patient and she was safely discharged. The monthly ETT showed a completely restored ventricular function. No further complications occurred during the follow-up and the patient was taken in charge by the Neurosurgery service. The presented case is of great interest as it shows a mid-ventricular Takotsubo cardiomyopathy, which is a rare subtype. The clinical presentation was not typical, not including chest pain and/or dyspnoea, but only asthenia before the acute event (apart from the neurological symptoms): this highlights how the scenario can sometimes be more nuanced. The EKG was also atypical, given the absence of the classical ST-segment elevation: only a mild QT prolongation and a slight lateral ST-depression in the precordial leads were present. TTE and coronary angiography play a pivotal role in making a prompt diagnosis and ruling out possible complications. Early initiation of medical therapy, as in our case, is of primary importance to assure a complete recovery of systolic ventricular function.