title: Cardiomyopathy with inverted tako-tsubo pattern in the setting of subarachnoid hemorrhage: a series of four cases.
abstract: BACKGROUND
  Severe subarachnoid hemorrhage may be associated with regional wall motion abnormalities (RWMA) in the absence of epicardial coronary occlusion. The RWMA extends beyond the distribution of a single coronary artery and may present in a typical tako-tsubo cardiomyopathy pattern. Other variants have also been recognized, including an inverted tako-tsubo pattern of severe basal hypokinesis that spares the apex. The mechanism of this cardiomyopathy is not well understood but likely involves catecholamine excess. While classic tako-tsubo cardiomyopathy from emotional stress carries a favorable prognosis, cardiac dysfunction from subarachnoid hemorrhage is a marker of overall poor prognosis.
  
  
  METHODS
  We collected cases over a period of 4 years at a large teaching hospital. The cases represent cardiac dysfunction in the setting of subarachnoid hemorrhage in the unusual distribution of basal hypokinesis with relative sparing of the apex (inverted tako-tsubo pattern).
  
  
  RESULTS
  A total of four cases were identified. All cases were female between the ages 43-67 years and had echocardiographic evidence of basal hypokinesis after suffering from an intracranial hemorrhage.
  
  
  CONCLUSIONS
  The typical and inverted patterns may represent a spectrum within the same disease process or distinct clinical entities with dramatically different prognostic implications. Larger studies comparing the two presentations will help elucidate this further.
authors.affiliation: Division of Cardiology, Emory University School of Medicine, 1365 Clifton Road, NE, 30322, Atlanta, GA, USA. sshouka@emory.edu
authors.forename: Sana
authors.initials: S
authors.lastname: Shoukat
authors.forename: Ahmed
authors.initials: A
authors.lastname: Awad
authors.forename: Douglas K
authors.initials: DK
authors.lastname: Nam
authors.forename: Michael H
authors.initials: MH
authors.lastname: Hoskins
authors.forename: Owen
authors.initials: O
authors.lastname: Samuels
authors.forename: Jason
authors.initials: J
authors.lastname: Higginson
authors.forename: Stephen D
authors.initials: SD
authors.lastname: Clements
mesh_terms: D000328:Adult; D000368:Aged; D002533:Cerebral Angiography; D003402:Creatine Kinase / Q000097:blood; D004452:Echocardiography; D004562:Electrocardiography; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D008875:Middle Aged; D012720:Severity of Illness Index; D013345:Subarachnoid Hemorrhage / Q000150:complications*; D054549:Takotsubo Cardiomyopathy / Q000201:enzymology / Q000209:etiology* / Q000503:physiopathology*; D014057:Tomography, X-Ray Computed; D019210:Troponin I / Q000097:blood
chemical_list: D019210:Troponin I; D003402:Creatine Kinase