Catapano Joshua S, Ducruet Andrew F, Frisoli Fabio A, Nguyen Candice L, Louie Christopher E, Labib Mohamed A, Baranoski Jacob F, Cole Tyler S, Whiting Alexander C, Albuquerque Felipe C, Lawton Michael T
J Neurosurg. 2020 Sep 4;135(1):38-43. doi: 10.3171/2020.5.JNS20536.
Takotsubo cardiomyopathy (TC) in patients with aneurysmal subarachnoid hemorrhage (aSAH) is associated with high morbidity and mortality. Previous studies have shown that female patients presenting with a poor clinical grade are at the greatest risk for developing TC. Intra-aortic balloon pumps (IABPs) are known to support cardiac function in severe cases of TC, and they may aid in the treatment of vasospasm in these patients. In this study, the authors investigated risk factors for developing TC in the setting of aSAH and outcomes among patients requiring IABPs.
The authors retrospectively reviewed the records of 1096 patients who had presented to their institution with aSAH. Four hundred five of these patients were originally enrolled in the Barrow Ruptured Aneurysm Trial, and an additional 691 patients from a subsequent prospectively maintained aSAH database were analyzed. Medical records were reviewed for the presence of TC according to the modified Mayo Clinic criteria. Outcomes were determined at the last follow-up, with a poor outcome defined as a modified Rankin Scale (mRS) score > 2.
TC was identified in 26 patients with aSAH. Stepwise multivariate logistic regression analysis identified female sex (OR 8.2, p = 0.005), Hunt and Hess grade > III (OR 7.6, p < 0.001), aneurysm size > 7 mm (OR 3, p = 0.011), and clinical vasospasm (OR 2.9, p = 0.037) as risk factors for developing TC in the setting of aSAH. TC patients, even with IABP placement, had higher rates of poor outcomes (77% vs 47% with an mRS score > 2, p = 0.004) and mortality at the last follow-up (27% vs 11%, p = 0.018) than the non-TC patients. However, aggressive intra-arterial endovascular treatment for vasospasm was associated with good outcomes in the TC patients versus nonaggressive treatment (100% with mRS ≤ 2 at last follow-up vs 53% with mRS > 2, p = 0.040).
TC after aSAH tends to occur in female patients with large aneurysms, poor clinical grades, and clinical vasospasm. These patients have significantly higher rates of poor neurological outcomes, even with the placement of an IABP. However, aggressive intra-arterial endovascular therapy in select patients with vasospasm may improve outcome.
动脉瘤性蛛网膜下腔出血（aSAH）患者发生的应激性心肌病（TC）与高发病率和死亡率相关。既往研究表明，临床分级较差的女性患者发生TC的风险最高。主动脉内球囊反搏（IABP）已知可在TC重症病例中支持心脏功能，且可能有助于治疗这些患者的血管痉挛。在本研究中，作者调查了aSAH情况下发生TC的危险因素以及需要IABP治疗的患者的预后情况。
作者回顾性分析了1096例因aSAH就诊于其机构的患者的记录。其中405例患者最初纳入了巴罗破裂动脉瘤试验，另外对来自后续前瞻性维护的aSAH数据库的691例患者进行了分析。根据改良的梅奥诊所标准，对病历进行审查以确定是否存在TC。在最后一次随访时确定预后情况，不良预后定义为改良Rankin量表（mRS）评分>2。
在26例aSAH患者中发现了TC。逐步多因素逻辑回归分析确定女性（比值比8.2，p = 0.005）、Hunt和Hess分级>III（比值比7.6，p < 0.001）、动脉瘤大小>7 mm（比值比3，p = 0.011）以及临床血管痉挛（比值比2.9，p = 0.037）是aSAH情况下发生TC的危险因素。即使置入IABP，TC患者的不良预后发生率（mRS评分>2时为77% vs 47%，p = 0.004）和最后一次随访时的死亡率（27% vs 11%，p = 0.018）仍高于非TC患者。然而，与非积极治疗相比，积极的动脉内血管内治疗血管痉挛与TC患者的良好预后相关（最后一次随访时mRS≤2为100% vs mRS>2为53%，p = 0.040）。
aSAH后的TC往往发生在患有大动脉瘤、临床分级差和临床血管痉挛的女性患者中。即使置入IABP，这些患者的神经功能不良预后发生率仍显著更高。然而，对部分血管痉挛患者进行积极的动脉内血管内治疗可能改善预后。
