Concurrent subarachnoid haemorrhage and myocardial injury

Subarachnoid haemorrhage is frequently associated with myocardial injury and dysfunction. This report describes such a case, reviews the understanding of this phenomenon, and discusses the implications for timing of surgical clipping of intracranial aneurysm in patients with concurrent myocardial damage.

A 64-yr-old women presented with syncope and congestive heart failure. A diagnosis of subarachnoid haemorrhage was made three days following the initial diagnosis of myocardial infarction. The patient presented for clipping of an intracranial aneurysm on day 36, after her cardiac status had stabilized. No new myocardial ischaemic events occurred, either intra-operatively or post-operatively. Ultimate neurological recovery was poor.

This case report demonstrates four important aspects of the clinical course of patients with concurrent subarachnoid haemorrhage and myocardial damage: 1) On presentation, cardiac features may predominate, and delay diagnosis and treatment of the underlying subarachnoid haemorrhage. 2) Left ventricular dysfunction, although dramatic, is usually transient. 3) There is confusion regarding the appropriate cardiac risk assessment and management in such patients when presenting for surgery. 4) Long-term morbidity is most often related to neurological, not medical, complications.