Department of Radiology, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Blvd. Dallas, TX, 75390
*Arzu Canan, Department of Radiology, University of Texas Southwestern Medical Center at Dallas, 5323
Harry Hines Blvd. Dallas, TX, 75390
Case presentation
A 61-year-old woman with acute encephalopathy and acute cholecystitis, was found to have elevated troponin (high-sensitive troponin: 978 ng/L; >52 ng/L: abnormal), regional wall motion abnormality of mid anterior and septal segments and 50% LVEF on transthoracic echocardiography (Movie 1), without EKG changes. Patient denied chest pain, shortness of breath or palpitation. Subsequent CTA demonstrated no coronary artery disease.
Cardiac MRI revealed LVEF 45%, focal akinesis of mid anterior and septal segments (Movie 2), and mild native T1 and T2 elevation without late gadolinium enhancement (Figure 1). Considering the concomitant medical stress and spontaneous troponin down titration (978 à 764 à711 ng/L), the patient was diagnosed with focal Takotsubo cardiomyopathy. Follow-up echocardiogram two weeks later demonstrated full recovery of wall motion abnormalities and 59% LVEF (Movie 3).
Takotsubo cardiomyopathy is usually associated with physical-emotional trigger and characterized by a variety of wall-motion abnormalities and transient LV dysfunction. Neurological disorders is a well-known trigger of Takotsubo cardiomyopathy and is more compared to patients with acute coronary syndromes. Although common presentation is acute chest pain, incidental troponin elevation or EKG changes can be the only finding. The most common type is the apical involvement resulting in apical ballooning. Isolated mid ventricular or basal involvement can also be seen. Focal anterior wall involvement is the rarest form and may mimic acute myocardial stunning or focal myocarditis. Small group of patient can have abnormal LGE while the majority of cases do not demonstrate any abnormal enhancement which can be helpful in distinguishing from other entities in addition to clinical and other ancillary findings.
Figure 1:
(a) 2-chamber steady state free precession still image in diastolic phase demonstrates minimal wall thinning of the mid anterior segment.
(b) 2-chamber steady state free precession still image in systolic phase shows focal akinesia of mid anterior segment resulting in focal bulging (arrow). Note the normal contraction at the basal and apical segments.
(c) 2-chamber phase sensitive inversion recovery (PSIR) image shows no late gadolinium enhancement.
Movie Legends:
Movie 1: Parasternal long axis view from the initial transthoracic echocardiography demonstrates the focal wall motion abnormality in the mid septal segment.
Movie 2: 2-chamber (a) and 3-chamber (b) steady state free precession cine clips from cardiac MRI demonstrates the mid anterior and septal wall motion abnormality.
Movie 3: Parasternal long axis view from the follow-up transthoracic echocardiography demonstrates the resolution of previously identified wall motion abnormality in the mid septal segment. Also note that, overall LV function has improved.
