Letter to the Editor
Takotsubo cardiomyopathy associated with cerebral infarction following surgery for euthyroid goitre
Síndrome de Takotsubo asociado a infarto cerebral en postoperatorio de bocio eutiroideo
a Unidad de Cirugía Endocrina, Servicio de Cirugía General, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biomédica (IMIB), El Palmar, Murcia, Spain
b Servicio de Neurología, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biomédica (IMIB), El Palmar, Murcia, Spain
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Febrero, J.M. Rodríguez, A. Morales, P. Parrilla" "autores" => array:4 [ 0 => array:4 [ "nombre" => "B." "apellidos" => "Febrero" "email" => array:1 [ 0 => "beatrizfebrero@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J.M." "apellidos" => "Rodríguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "A." "apellidos" => "Morales" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "P." "apellidos" => "Parrilla" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad de Cirugía Endocrina, Servicio de Cirugía General, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biomédica (IMIB), El Palmar, Murcia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Neurología, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biomédica (IMIB), El Palmar, Murcia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Síndrome de Takotsubo asociado a infarto cerebral en postoperatorio de bocio eutiroideo" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Takotsubo cardiomyopathy or stress cardiomyopathy is a disease characterised by acute, transient involvement of the left ventricular apex; it may be triggered by emotional or physiological stressors, including neurological complications.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> In the context of thyroid disease, takotsubo cardiomyopathy has mainly been associated with thyrotoxicosis.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a patient with takotsubo cardiomyopathy and stroke following thyroidectomy.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Our patient was a 74-year-old woman with arterial hypertension, dyslipidaemia, type 2 diabetes mellitus, and depressive disorder. A CT scan performed due to recurrent bronchitis revealed intrathoracic goitre. The patient reported mild discomfort with swallowing and displayed normal thyroid hormone levels. A thyroidectomy was performed by a cervical approach, with no complications; at discharge, she was instructed to take levothyroxine 100 μg every 24 hours. The patient visited the emergency department 8 days later due to a sudden-onset episode of difficulty speaking and chest pain. In-hospital code stroke was activated. The examination revealed symptoms of moderate aphasia, hemianopsia, and mild right-limb hemiparesis (4/5); the patient scored 7 on the National Institutes of Health Stroke Scale (NIHSS). An emergency CT scan was performed as part of the code stroke protocol. The CT perfusion study revealed a pattern compatible with acute subcortical stroke in the left parietal and piriform areas, with 30% mismatch without large-vessel occlusion. Fibrinolysis was the only reperfusion therapy possible in this case, but was contraindicated due to the recent surgery. The patient was therefore admitted to the stroke unit and remained under observation. Laboratory analyses showed a troponin T level of 67 ng/L (normal range, 0-14), TSH of 6.02 µIU/mL (0.27-4.2), and free T4 of 0.99 ng/dL (0.93-1.7). Electrocardiography showed sinus rhythm at 100 bpm, with negative T waves in leads V4-V6. Echocardiography detected circumferential hypokinesis in the left ventricular apex with ejection fraction in the lower limit of normal. An angiography study of the coronary arteries detected no alterations. These findings are compatible with takotsubo cardiomyopathy. Treatment with anticoagulants and beta blockers started at admission improved the patient’s symptoms, and she was discharged 21 days later with mild dysphasia and difficulty reading (NIHSS 1). An echocardiography performed at 3 months showed recovery of cardiac motility and normal ejection fraction. At present, the patient has no neurological or cardiological symptoms.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Takotsubo cardiomyopathy is characterised by transient dysfunction of the left ventricular apex, which presents with symptoms similar to those of myocardial infarction, but in the absence of coronary artery disease. Patients with takotsubo cardiomyopathy present electroencephalography alterations and moderately elevated troponin levels. The pathogenesis of the disease is unclear; an association with a hyperadrenergic state has been suggested.</p><p id="par0025" class="elsevierStylePara elsevierViewall">With regard to thyroid disease, takotsubo cardiomyopathy has mainly been associated with hyperthyroidism,<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–6</span></a> but cases have also been described in patients with hypothyroidism, since they may present autonomous nervous system alterations in the form of coronary artery spasm.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Our patient, however, presented subclinical hypothyroidism.</p><p id="par0030" class="elsevierStylePara elsevierViewall">She was a postmenopausal woman, a profile that is consistent with most of the cases reported.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Some series also report history of such cardiovascular risk factors as arterial hypertension (58%), diabetes mellitus (20%), and dyslipidaemia (37%).<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Affective disorders may present in up to 42% of patients.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">This is the first reported case of takotsubo cardiomyopathy manifesting as stroke after surgery for goitre. The condition is triggered by a stressor in 25%-35% of cases.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> Templin et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> report neurological involvement in 27% of a sample of 1750 patients with takotsubo cardiomyopathy, and other cases have been reported of epileptic seizures,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> subarachnoid haemorrhage,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> and ischaemic stroke.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11–13</span></a> Likewise, cerebrovascular accidents may present during follow-up as a complication of takotsubo cardiomyopathy in up to 8% of cases.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In our case, it is difficult to determine whether the stroke was the cause or the result of takotsubo cardiomyopathy.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The first option seems less likely, since the strokes that cause this type of cadiomyopathy have been associated with left insula involvement,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> whereas our patient presented a stroke in the left subcortical parietal and piriform region, which is not directly associated with the insula.</p><p id="par0045" class="elsevierStylePara elsevierViewall">This issue also has therapeutic implications. If cardiomyopathy were caused by stroke, the stroke would be cryptogenic and a more thorough aetiological study would be necessary. If, on the contrary, cardiomyopathy were the cause of stroke, the patient should receive anticoagulation therapy. We opted for the second hypothesis. After prolonged cardiac monitoring, we decided to suspend anticoagulation therapy, assuming that the cause of stroke had resolved.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In conclusion, takotsubo cardiomyopathy is a multifactorial disease that should be considered in some patients with thyroid disorders. Neurological disease may be the cause or a consequence of the syndrome. This issue should be analysed in future studies to gain a deeper understanding of the pathophysiology of the condition in association with neurological involvement.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-10-27" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Febrero B, Rodríguez JM, Morales A, Parrilla P. Síndrome de Takotsubo asociado a infarto cerebral en postoperatorio de bocio eutiroideo. Neurología. 2020;35:592–593.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Takotsubo cardiomyopathy: a new form of acute, reversible heart failure" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Y.J. Akashi" 1 => "D.S. Goldstein" 2 => "G. Barbaro" 3 => "T. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 1 | 4 |
| 2024 October | 19 | 6 | 25 |
| 2024 September | 19 | 15 | 34 |
| 2024 August | 18 | 13 | 31 |
| 2024 July | 16 | 8 | 24 |
| 2024 June | 18 | 6 | 24 |
| 2024 May | 7 | 1 | 8 |
| 2024 April | 25 | 6 | 31 |
| 2024 March | 9 | 6 | 15 |
| 2024 February | 22 | 8 | 30 |
| 2024 January | 19 | 5 | 24 |
| 2023 December | 19 | 5 | 24 |
| 2023 November | 19 | 7 | 26 |
| 2023 October | 22 | 12 | 34 |
| 2023 September | 11 | 2 | 13 |
| 2023 August | 12 | 4 | 16 |
| 2023 July | 20 | 4 | 24 |
| 2023 June | 20 | 1 | 21 |
| 2023 May | 46 | 3 | 49 |
| 2023 April | 47 | 1 | 48 |
| 2023 March | 10 | 2 | 12 |
| 2023 February | 14 | 5 | 19 |
| 2023 January | 12 | 1 | 13 |
| 2022 December | 11 | 2 | 13 |
| 2022 November | 14 | 6 | 20 |
| 2022 October | 11 | 7 | 18 |
| 2022 September | 14 | 11 | 25 |
| 2022 August | 19 | 8 | 27 |
| 2022 July | 15 | 11 | 26 |
| 2022 June | 15 | 8 | 23 |
| 2022 May | 13 | 10 | 23 |
| 2022 April | 17 | 6 | 23 |
| 2022 March | 13 | 6 | 19 |
| 2022 February | 27 | 2 | 29 |
| 2022 January | 27 | 7 | 34 |
| 2021 December | 15 | 22 | 37 |
| 2021 November | 11 | 9 | 20 |
| 2021 October | 37 | 8 | 45 |
| 2021 September | 25 | 17 | 42 |
| 2021 August | 11 | 7 | 18 |
| 2021 July | 19 | 5 | 24 |
| 2021 June | 16 | 17 | 33 |
| 2021 May | 18 | 10 | 28 |
| 2021 April | 29 | 30 | 59 |
| 2021 March | 19 | 11 | 30 |
| 2021 February | 10 | 5 | 15 |
| 2021 January | 11 | 2 | 13 |
| 2020 December | 16 | 12 | 28 |
| 2020 November | 8 | 4 | 12 |
| 2020 October | 14 | 9 | 23 |
| 2020 September | 0 | 4 | 4 |
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