Myocardial stunning secondary to aneurysmal subarachnoid hemorrhage

Although subarachnoid hemorrhage (SAH) is often associated with electrocardiographic abnormalities, profound effects on cardiac performance are rare.

A 57-year-old woman who developed loss of consciousness, respiratory distress, severe hypotension, and left ventricular hypokinesis with minimal coronary artery disease is described. Despite normal appearance of the coronary arteries on angiography, left ventricle function was so severely depressed that she required intra-aortic balloon pump support for 24 hours. Mental status changes prompted a head computed tomographic (CT) scan, which showed severe SAH and an intraventricular hemorrhage (IVH). Cerebral angiography demonstrated a basilar apex aneurysm. An echocardiogram done on hospital day 6 was normal. A left frontal ventriculostomy catheter was placed. This was later changed to a lumbar subarachnoid (SA) drain. The patient underwent an orbito-zygomatic craniotomy and aneurysm clipping. Although several serious medical problems occurred during her hospitalization, at follow-up, her sole neurological impairment was a minimal and resolving oculomotor paresis.

This patient's respiratory failure and severe hypotension were initially thought to be due to a chemical pneumonitis or a cardiomyopathy. However, her symptoms ultimately proved to be secondary to a ruptured basilar apex aneurysm. The complex relationship of SAH to myocardial stunning, as illustrated by this patient, is discussed.