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\begin{document}

\title{A FIRST CASE OF INCIDENTAL CEREBRAL ANEURYSM AFTER TAKOTSUBO
CARDIOMYOPATHY: A CASE REPORT}



\author[1]{Tânia Amaro}%
\author[2]{Taynara Sgarbi}%
\author[3]{Raísa Vieira}%
\author[4]{Rafael Reis Santos}%
\author[3]{Priscila Matos}%
\author[5]{Adilson Oliveira}%
\affil[1]{Clínica Girassol}%
\affil[2]{Universidade de Franca}%
\affil[3]{Universidade Estacio de Sa}%
\affil[4]{faculdade de medicina da universidade do para}%
\affil[5]{FMUAN}%


\vspace{-1em}



  
  \date{May 27, 2024}


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\textbf{INTRODUCTION}

Takotsubo syndrome is an acute heart disease that mimics the typical
features of acute coronary syndrome (ACS) {[}1{]}. Although takotsubo
syndrome has an uncertain prevalence in the general population, in women
with suspected ACS, the prevalence is estimated to be around 5-6\%
{[}2{]}. The annual incidence is very low and is approximately 0.02\%
{[}3{]}{[}4{]}.

Unlike ACS, TS is reversible and the heart often heals within four to
eight changes weeks. The syndrome is characterised by transient systolic
and diastolic left ventricular dysfunction with wall motion
abnormalities {[}5{]}{[}6{]}. This condition, which was first described
by Dote et al. in Japan in 1990 {[}3{]}{[}4{]}, usually affects
postmenopausal women who have experienced some physical or psychological
stress. However, it can also occur in the absence of these triggers
{[}1{]}{[}7{]}.

The prevalence of saccular aneurysms in the general population is
estimated at 3.2\%. Approximately 20 to 30\% of cases present in the
form of multiple aneurysms {[}8{]}. Intracranial aneurysms are generally
diagnosed after episodes of subarachnoid haemorrhage (SAH), which causes
a high rate of morbidity and mortality {[}9{]}. Rupture of an aneurysm
is believed to be responsible for 0.4 to 0.6\% of all aneurysm deaths,
and approximately 10\% of patients die before arriving at the hospital.
{[}10{]}

Takotsubo syndrome is generally reported to have an incidence of
0.8-17\% in patients with SAH caused by ruptured aneurysm {[}11{]}.
However, this case report is relevant for the clinical and
pathophysiological observation of the possible association between
aneurysms of the internal carotid arteries (ICA) and TS, with the latter
being able to serve as an alert for possible aneurysms and thus allow
for intervention prior to disruption.

\textbf{CASE PRESENTATION:}

A 54-year-old female had a history of systemic arterial hypertension and
migraine. She had previously been treated with atenolol 25 mg once daily
and hydrochlorothiazide 25 mg once daily. She sought medical care at a
secondary hospital due to chest pain, which began suddenly 2h before
admission and had irradiated to the left upper limb and back. The
initial electrocardiogram (EKG) was normal but showed a troponin curve
(33,38 ng/l, 26,42 ng/l, 13,82 ng/l), which led to the hypothesis of
non-ST elevation myocardial infarction, Killip I. Loading doses of
acetylsalicylic acid (ASA) 300 mg, clopidogrel 300 mg, enoxaparin 60 mg,
and nitroglycerin were administered intravenously due to persistent
pain. The patient was later transferred to a tertiary hospital. Upon
admission she was lucid, oriented in time and space, and pain-free, with
the use of nitroglycerin 8 ml/h. Her blood pressure was 128/74 mmHg,
mean blood pressure was 92 mmHg, and heart rate was 78 bpm. Serial EKG
showed dynamic changes with ST-segment elevation in DIII, AvF, V5 and
V6\textbf{(Fig. 1)} . Therefore, urgent cardiac catheterisation was
performed, but it did not reveal any obstructive lesions. However,
ventriculography revealed hypokinesia in the inferoapical
wall\textbf{(Fig. 2)} , which supported the hypothesis of takotsubo
syndrome. During hospitalisation, the patient experienced a severe
refractory headache. Computed tomography (CT) of the head was performed
under suspicion of SAH, and the examination results were normal.
Subsequently, CT angiography (angio CT) of the head was performed to
rule out a rupture of the aneurism. The angio CT identified ''mirror''
saccular aneurysms in the ophthalmic segment of the ICAs. The largest
aneurysm was on the right, and in superior orientation the lesion
measured 5 mm x 4 mm with a neck of 3 mm \textbf{(Fig. 3).} The patient
was subsequently transferred from the cardiology unit to the intensive
care unit and underwent lumbar puncture. Clear and colourless cerebral
spinal fluid was observed after centrifugation, which confirmed the
absence of SAH. The patient was diagnosed with unerupted aneurysm and
underwent embolization of a supraclinoid ICA aneurysm using two stents
to contain the metal coil. This procedure had no complications. The
patient progressed satisfactorily and was discharged with a
recommendation for outpatient follow-up in the general cardiology
department. She was treated with enalapril, atenolol, atorvastatin, and
ASA/clopidogrel.

\textbf{DISCUSSION:}

The association between takotsubo syndrome and aneurysmal SAH in some
populations has previously been reported. Therefore, it was necessary to
perform screening for SAH and the discovery of an unruptured aneurysm in
this case report {[}12, 13{]}.

To the best of our knowledge, this is the first report of takotsubo
syndrome and unruptured cerebral aneurysm. Therefore, we believe that
patients with a diagnosis of takotsubo syndrome should undergo an
angiography scan for cerebral aneurysm, due to the known risk of
rupture. Early diagnosis of aneurysms is possible, and acting in a
preventive manner with rapid institution of pre-rupture treatment
reduces morbidity and mortality. The present case report differs from
most cases of takotsubo syndrome described in the literature since it
presents unruptured mirror aneurysms, while most cases are diagnosed
after intracranial haemorrhage. Thus, to reduce morbidity and mortality,
screening for brain aneurysms should be performed as a preventive
protocol in patients diagnosed with takotsubo cardiomyopathy.

\textbf{Figure 1}\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

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Dynamic electrocardiogram change with ST elevation of DIII, AvF, V5 and
V6.

\textbf{Figure 2}\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

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Ventriculography showing hypokinesia in the inferoapical wall of the
heart.

\textbf{Figure 3}\selectlanguage{english}
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Cranial computed tomography angiography, which identified ''mirror''
saccular aneurysms in the ophthalmic segment of the internal carotid
arteries.

\textbf{STATEMENT OF CONSENT:} The authors confirm that written consent
for submission and publication of this case report, including images and
associated text, was obtained from the patient in line with the COPE
guidance.

\textbf{FUNDING:} None

\textbf{ACKNOWLEDGEMENTS:} None

\textbf{CONFLICT OF INTEREST:} The authors declare that they have no
conflict of interest

\textbf{REFERENCES:}

YHassan S, Tornvall P. Epidemiology, pathogenesis, and management of
Takotsubo syndrome. Clin Auton Res 2018;28:53-65.

\begin{enumerate}
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