Basement flooding causing cardioembolic stroke due to Tako-Tsubo cardiomyopathy

Background: Cardioembolic stroke is among the most common causes of ischemic stroke with an incidence of about 20%. Recently, a concept of stress-induced cardiomyopathy has been proposed – Tako-Tsubo cardiomyopathy (TTC). Here we present the neurological and cardiological features of a patient who developed ischemic stroke after flooding of her houses' basement due to heavy rain.

Case presentation: A 68 year old woman presented with acute rightsided hemiparesis, hemihypoesthesia and aphasia. She reported the flooding of her basement due to heay rain three days ago, an extremely stressful event acutely inducing chest pain, shortness of breath and panic. CCT on admission showed a hypodense left temporo-parietal area, confirmed to be ischemic by cranial diffusion MRI.

An acute coronary syndrome with elevated troponin I, ST segment depression and T wave inversions in ECG was diagnosed. Relevant coronary artery disease was excluded by cardiac angiography, but cardiac ultrasound revealed akinesia and ballooning of the left ventricular apical segment with concomitant thrombus formation, diagnostic for TTC. Heparin therapy was started.

Only consecutively, the patient developed atrial fibrillation, potentially also precipitated by hyperthyreosis. In addition, signs of renal infarction (impairment of renal clearance, LDH elevation, hematuria and lateral lower back pain) could be observed. As known for TTC, wall motion abnormalities and ventricular thrombus were completely resolved on echocardiography three weeks later. Over the time of hospitalisation, anomia and sensory and motor dysfunctions substantially improved.

Conclusion: As reported previously, TTC is an underdiagnosed possible cause of cardioembolic stroke following acute emotional (earthquakes, gambling loss) or physical stress. Therefore, history of stressful events at onset of cerebral ischemia should rapidly prompt cardiac assessment for TTC to avoid delays in anticoagulation and further systemic embolism. Although apical ventricular ballooning in TTC may suggest severe cardiac dysfunction as in other cardiomyopathies, TTC is known for its favourable outcome with normalized left ventricular function.

As in our patient, atrial fibrillation is commonly complicating TTC and may lead to further systemic embolism to other organs.