RESUMO
Complicações sistêmicas são vistas frequentemente em indivíduos acometidos por hemorragia subaracnóidea. Dentre estas alterações podem ocorrer anormalidades eletrocardiográficas que simulam miocardiopatia isquêmica que podem ou não estar associadas com disfunção miocárdica. O objetivo deste é relatar um caso de associação de hemorragia subaracnóidea com disfunção miocárdica e choque cardiogênico. Mulher de 45 anos foi internada com quadro de coma secundário a hemorragia subaracnóidea. À admissão apresentava Glasgow = 7, Hunt-Hess = 5 e classificação tomográfica de Fisher = 3. O aneurisma cerebral de artéria comunicante anterior evidenciado pela arteriografia cerebral foi embolizado com sucesso no segundo dia de internação. Evoluiu com dispnéia e infiltrado pulmonar difuso. Havia alteração da repolarização ventricular em parede lateral, aumento da CK-MB (36 U/L) e hipotensão. O índice cardíaco de 2,03 L/min/m², a resistência vascular sistêmica 3728 dynes.seg/cm5/m², e a irresponsividade a volume evidenciavam o padrão hemodinâmico de choque cardiogênico. A fração de ejeção do ventrículo esquerdo era de 39 por cento. A cineangiocoronariografia não apresentava lesões coronarianas obstrutivas. Após 6 dias a paciente foi extubada e ao oitavo dia foi possível a retirada completa da dobutamina. A fração de ejeção passou a 65 por cento. Sucessivos exames de Doppler transcraniano não apresentaram vasoespasmo. A paciente recebeu alta da unidade de terapia intensiva no décimo quarto dia. Pacientes com hemorragia subaracnóidea podem apresentar disfunção ventricular e choque cardiogênico, aumentando o risco de isquemia cerebral. O diagnóstico e a otimização hemodinâmica são essenciais para minimizar os riscos de vasoespasmo e isquemia cerebral.
Systemic complications are frequent in subarachnoid hemorrhage patients. Among these complications, electrocardiographic abnormalities simulating ischemic cardiomyopathy may occur, possibly associated with myocardial dysfunction. This manuscript aims to report a case of subarachnoid hemorrhage associated with myocardial dysfunction and cardiogenic shock. A 45 years old woman was admitted with subarachnoid hemorrhage and coma, showing Glasgow scale = 7, Hunt-Hess = 5 and Fischer computed tomography classification = 3. On the second day, the patient underwent anterior cerebral communicant artery aneurysm embolization. The clinical evaluation revealed diffuse pulmonary infiltration, dyspnea and hypotension. Additional tests showed electrocardiographic lateral wall repolarization changes and elevated creatine kinase-MB fraction (36U/L). The cardiac index was 2.03 L/minute/m², Vascular systemic resistance was 3728 dynes.sec/cm². The non-responsiveness to volume demonstrated a cardiogenic shock pattern. The ventricular ejection fraction was 39 percent. The coronariography was normal, showing no obstructive lesions. Six days later the patient was removed from respiratory support and after eight days the dobutamine infusion was discontinued. The ejection fraction recovered up to 65 percent. Serial transcranial Doppler evaluations did not show vascular spasm. After ten days the patient was discharged from the intensive care unit. Patients with subarachnoid hemorrhage may be complicated with ventricular dysfunction and cardiogenic shock, increasing the cerebral ischemia risk. Diagnosis optimization and hemodynamic stabilization are essential to minimize the risk of cerebral vasospasm and ischemia.
RESUMO
Systemic complications are frequent in subarachnoid hemorrhage patients. Among these complications, electrocardiographic abnormalities simulating ischemic cardiomyopathy may occur, possibly associated with myocardial dysfunction. This manuscript aims to report a case of subarachnoid hemorrhage associated with myocardial dysfunction and cardiogenic shock. A 45 years old woman was admitted with subarachnoid hemorrhage and coma, showing Glasgow scale = 7, Hunt-Hess = 5 and Fischer computed tomography classification = 3. On the second day, the patient underwent anterior cerebral communicant artery aneurysm embolization. The clinical evaluation revealed diffuse pulmonary infiltration, dyspnea and hypotension. Additional tests showed electrocardiographic lateral wall repolarization changes and elevated creatine kinase-MB fraction (36U/L). The cardiac index was 2.03 L/minute/m², Vascular systemic resistance was 3728 dynes.sec/cm². The non-responsiveness to volume demonstrated a cardiogenic shock pattern. The ventricular ejection fraction was 39%. The coronariography was normal, showing no obstructive lesions. Six days later the patient was removed from respiratory support and after eight days the dobutamine infusion was discontinued. The ejection fraction recovered up to 65%. Serial transcranial Doppler evaluations did not show vascular spasm. After ten days the patient was discharged from the intensive care unit. Patients with subarachnoid hemorrhage may be complicated with ventricular dysfunction and cardiogenic shock, increasing the cerebral ischemia risk. Diagnosis optimization and hemodynamic stabilization are essential to minimize the risk of cerebral vasospasm and ischemia.
