Szántó Dorottya, Luterán Péter, Gál Judit, Nagy Endre V, Fülesdi Béla, Molnár Csilla
Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary.
ELKH-DE Cerebrovascular Research Group, 4032 Debrecen, Hungary.
Rev Cardiovasc Med. 2023 Jun 19;24(6):177. doi: 10.31083/j.rcm2406177. eCollection 2023 Jun.
Takotsubo syndrome (TS) is a frequent complication of subarachnoid hemorrhage (SAH), especially in massive SAH with severe neurological damage. The initial presentation of TS is similar to acute coronary syndrome, causing differential diagnostic issues. Unnecessary diagnostic steps and uncertainty in therapy may delay the definitive treatment of the aneurysm, therefore increasing the risk of rebleeding. The purpose of this review is to summarize the latest knowledge on the diagnosis and therapy of TS in SAH and to provide a diagnostic and therapeutic algorithm for the acute phase, promoting the early definitive treatment of the aneurysm. Rapid hemodynamic stabilization and early aneurysm securing are key points in reducing the risk of delayed cerebral ischemia and improving outcomes. In acute SAH noninvasive bedside diagnostic methods are preferred and securing the aneurysm is the priority. The combination of electrocardiography, cardiac biomarkers, and echocardiography is of great importance in differentiating TS from acute myocardial infarction. The risk-benefit ratio of coronary angiography should be carefully and individually considered and its use should be limited to patients with strong evidence of myocardial ischemia, after the successful endovascular treatment of the aneurysm. Invasive hemodynamic monitoring may be beneficial in cases of cardiogenic shock or pulmonary edema. In patients with hemodynamical instability secondary to TS, the use of non-catecholamine inotropes, especially levosimendan is recommended. In refractory hypotension, mechanical support should be considered. The left ventricular function improves within days to months after the acute event, low initial ejection fraction may predispose to delayed recovery.
应激性心肌病（TS）是蛛网膜下腔出血（SAH）的常见并发症，尤其是在伴有严重神经损伤的大量SAH中。TS的初始表现类似于急性冠状动脉综合征，会引发鉴别诊断问题。不必要的诊断步骤和治疗的不确定性可能会延迟动脉瘤的确定性治疗，从而增加再出血的风险。本综述的目的是总结SAH中TS诊断和治疗的最新知识，并提供急性期的诊断和治疗算法，以促进动脉瘤的早期确定性治疗。快速的血流动力学稳定和早期动脉瘤夹闭是降低延迟性脑缺血风险和改善预后的关键。在急性SAH中，首选无创床边诊断方法，动脉瘤夹闭是首要任务。心电图、心脏生物标志物和超声心动图的联合应用对于鉴别TS和急性心肌梗死非常重要。冠状动脉造影的风险效益比应仔细且个体化地考虑，其应用应限于在动脉瘤成功进行血管内治疗后有强烈心肌缺血证据的患者。在发生心源性休克或肺水肿的情况下，有创血流动力学监测可能有益。对于因TS继发血流动力学不稳定的患者，建议使用非儿茶酚胺类正性肌力药物，尤其是左西孟旦。在难治性低血压中，应考虑机械支持。急性事件发生后数天至数月内左心室功能会改善，初始射血分数低可能易导致恢复延迟。
