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A Rare case of Tako Tsubo Syndrome treated at Apollo Hospitals, Delhi !

Date: 10 Aug 2011

Doctors at Indraprastha Apollo Hospitals, Delhi treat a woman of Subarachnoid Brain Hemorrhage, assumed as a case of cardiac disorder at other hospitals.

Mr Umed Singh, a simple farmer from Ballabhgarh in Haryana had all the reasons to be restless and despondent. Condition of his 42 years-old wife, Mrs Omwati was deteriorating steadily and rapidly. They had been shuttling between hospitals but the doctors could not diagnose the appropriate cause of her deteriorating health. Her blood pressure was low; it required continuous intravenous infusion of two powerful medicines to boost it. She had become drowsy and was unable to respond coherently to even simple questions. It all started early in the morning when she experienced headache. She was drenched with sweat the very next moment and was complaining of pain in chest and palpitation. She had difficulty in breathing and continued to vomit regularly. "She is very serious" was all that was told by the doctors at the first hospital she was taken to.

She underwent several tests, which included an ECG, a 2D echocardiogram and an x-ray of chest. She also underwent a CT scan of head. Doctors informed him that his wife had not one but two problems. She had a massive heart attack. Her heart was failing; it was working at only 20% its capacity. In addition to this, she also had massive brain hemorrhage - possibly due to a ruptured aneurysm.

Mr. Umed admitted his wife to the Indraprastha Apollo Hospital, New Delhi. Medical problems of Mrs Omwati posed several challenges for the doctors at the Apollo Hospital. The ECG, 2D echocardiogram, x-ray chest and even the cardiac enzymes were strongly supporting the diagnosis of heart attack. Despite these, the doctors could quickly figure out that the "heart attack" was actually a manifestation of the brain hemorrhage. She was examined by a cardiologist and by Dr Pranav Kumar, Senior Consultant Neurosurgeon at Apollo Delhi.

"We do see certain ECG changes in many patients of brain hemorrhage. In extremely rare cases, a hemorrhage can produce cardiac changes as severe as seen in this case. This was one of those extremely rare cases where subarachnoid hemorrhage (a type of brain hemorrhage) presents as typical heart attack (myocardial infarction). This is because of release of certain chemicals from the brain, which, in turn produces changes in the heart. Japanese doctors have called it Tako Tsubo syndrome. It has also been called "stunned myocardium". Medically the disease is referred as subarachnoid hemorrhage induced cardiomyopathy," said Dr Pranav Kumar.

It took two days to stabilize her heart and the blood pressure. A subsequent coronary angiogram confirmed what the doctors had initially guessed. She did not have a "true" heart attack. The primary problem lay in brain, which required the main treatment while the heart only required supportive care. Once the heart had been stabilized, the doctors carried out a complex, six-hour microsurgery on her brain in which they put a titanium clip across the neck of the aneurysm she had. The aneurysm cannot rupture again. Though the surgery was successful, Omwati was not yet out of danger. She continued to require intensive care over the next few days. She recovered slowly. Tests carried out just before the discharge revealed almost complete recovery of heart.

Dr Kumar says, "The symptoms of this syndrome are very similar to that of a Myocardial Infarction. Subarachnoid Brain Hemorrhage (SAH) induced cardiac changes can mimic acute MI. Such cardiac changes are completely reversible. Its presence, however severe, should not discourage the neurosurgeon or neurologist from pursuing appropriate management of SAH / aneurysm."

Omwati and Umed Singh feel that Dr Pranav Kumar had given her a new lease of life and is grateful to the entire staff at Apollo Hospitals, Delhi for instilling the confidence of living in her when she had lost all hopes.

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