Diagnosis and Management of Takotsubo Syndrome in Acute Aneurysmal Subarachnoid Hemorrhage: A Comprehensive Review

Fig. 1.. Differences in cardiac troponin T between study groups from day 1 to 7 after SAH. Reproduced with permission from Molnár et al. [15]. Boxplots show the median, upper, and lower quartiles, and minimum and maximum values, with outliers omitted for clarity. Differences are highly significant each day (p < 0.001). CTNT: cardiac troponin T (ng/L); Contol: control SAH patients; Moderate: patients with SAH plus TS, EF >40%; Severe: patients with SAH plus TS, EF <40%. SAH, subarachnoid hemorrhage; TS, Takotsubo syndrome; EF, ejection fraction.

Fig. 2.. Differences in N terminal prohormone of brain natriuretic peptide between study groups from day 1 to day 7 after SAH. Reproduced with permission from Molnár et al. [15]. Boxplots show the median, upper, and lower quartiles, and minimum and maximum values, with outliers omitted for clarity. Differences are highly significant each day (p < 0.001). NT-proBNP: N terminal prohormone of brain natriuretic peptide (ng/L); Contol: control SAH patients; Moderate: patients with SAH plus TS, EF >40%; Severe: patients with SAH plus TS, EF <40%. SAH, subarachnoid hemorrhage; TS, Takotsubo syndrome; EF, ejection fraction.

Fig. 3.. Diagnostic algorithm for detection of Takotsubo syndrome in patients presenting with subarachnoid hemorrhage. TS, Takotsubo syndrome; SAH, subarachnoid hemorrhage; ECG, electrocardiography; CK-MB, creatinin kinase MB; NT-proBNP, N terminal prohormone of brain natriuretic peptide; WMA, wall motion abnormality; EF, ejection fraction; CAD, coronary artery disease; AMI, acute myocardil infarction; CCTA, coronary coputed tomography angiography; CMRI, cardiac magnetic resonance imagining; CA, coronary angiography. * AMI is more likely to be present in the following cases: RWMA in a single coronary artery distribution, male sex, elevated troponin level with failure to decay after the first day, and low-grade SAH [7]. The combination of troponin, CK-MB, and NT-proBNP, ECG changes and the reversibility of WMA may also help differentiate between TS and AMI [24, 42]. In contrast to myocardial infarction, age, and cardiovascular risk factors do not predispose to the development of TS [15, 33, 34, 35, 38]. **Coronary angiography is indicated in only those cases when the patient may benefit from the coronary intervention, considering the necessity and risk-benefit ratio of anticoagulant therapy.

Fig. 4.. Management algorithm of Takotsubo Syndrome in the acute phase of subarachnoid hemorrhage. ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; HF, heart failure; IABP, intra-aortic balloon pump; IV, intravenous; LVAD, left ventricular assist device; LVOTO, left ventricular outflow tract obstruction; TS, Takotsubo syndrome; VA-ECMO, venoarterial extracorporeal membrane oxygenation.