Europace Advance Access originally published online on April 27, 2008
Europace 2008 10(9):1115-1116; doi:10.1093/europace/eun107
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CASE REPORTS
Severe headache and a broken heart
1 Medizinische Klinik II, Universität zu Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany; 2 Klinik für Neurochirurgie, Universität zu Lübeck, Lübeck, Germany
Manuscript submitted 12 March 2008. Accepted after revision 2 April 2008.
* Corresponding author. Tel: +49 451 500 4859; fax: +49 451 500 5146. E-mail address: bonnemei{at}medinf.mu-luebeck.de
A 62-year-old sports teacher was admitted to the emergency room with progressively severe headaches, vomiting, left homonymous hemianopsia, weakness of the left arm and leg, and clouding of consciousness progressing over a few hours. The initial electrocardiogram (ECG) revealed new onset of atrial fibrillation with a ventricular rate of 170 bpm (Figure 1G). A computed tomography (CT) brain scan with contrast enhancement (Figure 1A) confirmed the presence of a large right lobar haemorrhage 
6 cm in diameter with some mass effect.
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During conservative treatment, the patient's symptoms resolved within 3 days and his neurological signs also improved quickly. A magnetic resonance imaging brain scan (Figure 1B) revealed no further increase of the lesion. However, a follow-up ECG now exhibited novel T-wave inversion in leads II, III, aVF, V3–V6, and downsloping ST-segment depression (Figure 1H). Furthermore, serum levels of cardiac troponin T (0.18 ng/mL) were elevated. The ECG displayed markedly impaired left ventricular (LV) function (left ventricular ejection fraction 29%) (Figure 1F). In view of these diagnostic findings and moderate dyspnea, the patient was referred for cardiac catheterization. Coronary angiography revealed insignificant coronary artery disease (Figure 1C). Left ventricular angiography confirmed a depressed ventricular function with an unusual pattern of wall motion abnormalities, characterized by an apical and lateral balloon-like dyskinesis and basal hypercontractility (Figure 1E and I). Single-photon emission computed tomography (SPECT) revealed that myocardial iodine-123 metaiodobenzylguanidine (123I-MIBG) uptake and 18F-fluoro-deoxy-glucose (18F-FDG) were reduced in the akinetic LV area, whereas technetium-99 m methoxyisobutylisonitrile (99 mTc-MIBI) SPECT indicated normal perfusion within this region (Figure 1D).
The association between intracerebral hemorrhage and cardiac dysfunction, reflected by ECG-changes, arrhythmia, and elevations of cardiac markers, is well known. However, the underlying pathophysiological mechanisms still remain unclear. Recently, the syndrome of ‘Takotsubo cardiomyopathy’, ‘apical ballooning’ or ‘broken heart syndrome’, characterized by a transient apical ballooning of the LV during states of exaggerated sympathetic activation, has been more and more recognized. Thus, both entities may provide a uniform pathophysiology, characterized by excessive cardiac sympathetic nervous discharge.
Conflict of interest: none declared.
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