The problem of neurogenic stunned myocardium in the intensive care practice

M.D. Bitchuk


The purpose of the review is to assess the prevalence of neurogenic stunned myocardium (SM), to determine the main pathological mechanisms of its formation and the principles of intensive care. Neurogenic SM is a condition characterized by a significant decrease in the pumping function of the heart in patients with neurological and neurosurgical disorders without acute myocardial necrosis. The greatest number of observations of SM phenomenon is described among patients with subarachnoid he-morrhage, traumatic brain injury, Guillain-Barre syndrome. The term “neurogenic SM” may be associated with cerebral-cardiac syndrome, as well as with other terms known as stress-induced cardiomyopathy, apical ballooning syndrome, ampulla cardiomyopathy, broken heart syndrome. Heart Failure Association of the European Society of Cardiology currently considers neurogenic SM as a particular case of takotsubo syndrome. The development of SM is associated with the adverse effect of the massive release of catecholamines into the blood under severe stress conditions, calcium overload of cardiomyocytes, excessive activation of free radical oxidation processes. The most severe clinical manifestations of SM are cardiogenic shock and centrogenic pulmonary edema. The most common and available methods for the clinical diagnosis of SM are electrocardiographic monitoring, detailed transthoracic ultrasound of the heart, transpulmonary thermodilution, and the determination of a moderate increase in the plasma concentration of cardiac troponins. Respiratory support and drugs with a positive inotropic effect are widely used as part of intensive care measures for neurogenic SM.


neurogenic stunned myocardium; stress; catecholamines; cerebral stroke; severe traumatic brain injury; central hemodynamics; cardiogenic shock; cardiac troponins; review


Go A.S., Mozaffarian D., Roger V.L., Benjamin E.J., Berry J.D., Blaha M.J. et al. Executive summary: heart disease and stroke statistics — 2014 update: a report from the American Heart Association. Circulation. 2014, Jan 21. 129(3). 399-410. doi: 10.1161/01.cir.0000442015.53336.12.

Go A.S., Mozaffarian D., Roger V.L., Benjamin E.J., Berry J.D., Borden W.B. et al. Executive summary: heart disease and stroke statistics — 2013 update: a report from the American Heart Association. Circulation. 2013, Jan 01. 127(1). 143-52. doi: 10.1161/CIR.0b013e318282ab8f.

Mishchenko T. Akademiia insultu: standartyzatsiia ta perspektyvy nadannia medychnoi dopomohy [Internet] Ukrainskyi medychnyi chasopys. 2015. 6(110). Available from: [Ukrainian].

Yakovtsov I.Z., Kursov S.V., Yakovtsova N.V., Shkurat A.M., Mustafa V.I. Problemy komorbidnoi patolohii: spoluchennia mozkovoho insultu ta hostroho infarktu miokarda. Materialy naukovoho konhresu z mizhnarodnoiu uchastiu «Problemni pytannia medytsyny nevidkladnykh staniv: teoretychni ta praktychni yikh aspekty» 23–24 kvitnia 2015, Vinnytsia: TOV Merkiuri Podillia, 2015. 190-192 [Ukrainian].

Yang Y., Shi Y.Z., Zhang N., Wang S., Ungvari G.S., Ng C.H. et al. The Disability Rate of 5-Year Post-Stroke and Its Correlation Factors: A National Survey in China. PLoS One. 2016, Nov 08. 11(11). Е0165341. doi: 10.1371/journal.pone.0165341.

Di Carlo A., Lamassa M., Franceschini M., Bovis F., Cecconi L., Pournajaf S. et al. Impact of acute-phase complications and interventions on 6-month survival after stroke. A prospective observational study. PLoS One. 2018, Mar 23. 13(3). Е0194786. Available from:

Kumar S., Selim M.H., Caplan L.R. Medical complications after stroke. Lancet Neurology. 2010, Jan. 9(1). 105-18. doi: 10.1016/S1474-4422(09)70266-2.

Civelek G.M., Atalay A., Turhan N. Medical complications experienced by first-time ischemic stroke patients during inpatient, tertiary level stroke rehabilitation. Journal of Physical Therapy Science. 2016, Feb. 28(2). 382-91. doi: 10.1589/jpts.28.382.

Chalela J.A., Jacobs T.L. Cardiac complications of stroke [Internet] UpToDate [last updated: Mar 01, 2019; cited 10 Jul, 2019] Available from:

Cheng C.Y., Hsu C.Y., Wang T.C., Jeng Y.C., Yang W.H. Evaluation of Cardiac Complications Following Hemorrhagic Stroke Using 5-Year Centers for Disease Control and Prevention (CDC) Database. Journal of Clinical Medicine. 2018, Dec 05. 7(12). 519. Available from:

Inamo J., Ozier-Lafontaine N., Olindo S. Left Ventricular Hypertrophy Diagnosed on ECG Also Predicts Early Mortality after Stroke. JACC: Cardiovascular Imaging. 2018, Mar. 11(3): 515-6. DOI: 10.1016/j.jcmg.2017.12.018.

Joundi R.A., Rabinstein A.A., Nikneshan D., Tu J.V., Fang J., Holloway R. et al. Cardiac Arrest in Acute Ischemic Stroke: Incidence, Predisposing Factors, and Clinical Outcomes. Journal of Stroke. 2016, Jul. 25(7). 1644-52. Available from:

Biso S., Wongrakpanich S., Agrawal A., Yadlapati S., Kishlyansky M., Figueredo V. A Review of Neurogenic Stunned Myocardium. Cardiovascular Psychiatry & Neurology. 2017, Aug 10. 2017. 5842182. doi: 10.1155/2017/5842182.

Braunwald E., Kloner R.A. The Stunned Myocardium: Prolonged, Postischemic Ventricular Dysfunction. Circulation. 1982, Dec. 66(6). 1146-9.

Duncker D.J., Schulz R., Ferrari R., Garcia-Dorado D., Guarnieri C., Heusch G. et al. «Myocardial stunning»: remaining questions. Cardiovascular Research. 1998, Jun 01. 38(3). 549-58.

Kerro A., Woods T., Chang J.J. Neurogenic stunned myocardium in subarachnoid hemorrhage. Journal of Critical Care. 2017. 38. 27-34. doi: 10.1016/j.jcrc.2016.10.010.

Lang R.M., Badano L.P., Mor-Avi V., Afilalo J., Armstrong A., Ernande L. et al. Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Journal of the American Society of Echocardiography. 2014, Jan. 28(1). Е1-e14.

Goliasch G., Binder T. Echo Facts. Wien, Publisher:, 2014. 252. Available from:

Anthony B., Ertler M., Cyr D.R., Binder T., Müller K., Bene C. et al. Free Lectures of Our Echo Master Class: Left Ventricular Function [Internet]; Medical University of Vienna [cited 10 Jul, 2019]. Available from:

Cecconi M., De Backer D., Antonelli M., Beale R., Bakker J., Hofer C. et al. Consensus on circulatory shock and hemodynamic mo-nitoring. Task force of the European Society of Intensive Care Medicine. Intensive Care Medicine. 2014, Dec. 40(12). 1795-815. DOI: 10.1007/s00134-014-3525-z.

McCanny P., Colreavy F., Bakker J., Vincent J.L., De Bac-ker D. Haemodynamic Monitoring & Management: Skills and Techniques, 2013. An ESICM multidisciplinary distance learning program for intensive care training. European Society of Intensive Care Medicine. DOI: 10.1007/s00134-014-3525-z.

Nikonov V.V., Kursov S.V., Zabashta V.F. Shok: suchasnyi pohliad na problemu ta nadannia medychnoi dopomohy na dohospitalnomu ta rannomu hospitalnomu etapi. Kharkiv: Madryd, 2019. 182 [Ukrainian].

Burns E. Myocardial Ischemia [Internet] Life in the Fastlane [last update March 16, 2019; cited May 02; 2019] Available from:

Critical Decisions in Emergency and Acute Car Electrocardiography / editors W.J. Brady & J.D. Truwit — Hong Kong: Wiley-Blackwell, 2009. 506. Available from:

Kligfield P., Gettes L.S., Bailey J.J., Childers R., Deal B.J., Hancock W. et al. Recommendations for the Standardization and Interpretation of the Electrocardiogram: Part I: The Electrocardiogram and Its Technology A Scientific Statement From the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society Endorsed by the International Society for Computerized Electrocardiology. Journal of the American College of Cardiology. 2007, Mar 13. 49(10). 1109-27.

Van der Bilt I.A., Hasan D., Vandertop W.P., Wilde A.A., Algra A., Visser F.C. et al. Impact of cardiac complications on outcome after aneurysmal subarachnoid hemorrhage: a meta-ana­lysis. Neurology. 2009, Feb 17. 72(7). 635-42. doi: 10.1212/01.wnl.0000342471.07290.07.

Van der Bilt I.A., Hasan D., van den Brink R., Cramer M.J., van der Jagt M., van Kooten F. et al. Cardiac dysfunction after aneurysmal subarachnoid hemorrhage: relationship with outcome. Neurology. 2014, Jan 28. 82(4). 351-8. doi: 10.1212/WNL.0000000000000057.

Parekh N., Venkatesh B., Cross D., Leditschke A., Atherton J., Miles W. et al. Cardiac Troponin I Predicts Myocardial Dysfunction in Aneurysmal Subarachnoid Hemorrhage. Journal of the American College of Cardiology. 2000, Oct. 36(4). 1328-35. DOI: 10.1016/s0735-1097(00)00857-3.

Jain R., Deveikis J., Thompson B.G. Management of Patients with Stunned Myocardium Associated with Subarachnoid Hemorrhage. American Journal of Neuroradiology. 2004, Jan. 25. 126-9. Available from:

Manikandan S. Cardiovascular manifestations of subarachnoid haemorrhage. Journal of Neuroanaesthesiology and Critical Care. 2017. 04(04). S38-S44. DOI: 10.4103/2348-0548.199947.

Adameova A., Abdellatif Y., Dhallaa N.S. Role of the excessive amounts of circulating catecholamines and glucocorticoids in stress-induced heart disease. Canadian Journal of Physiology and Pharmaco-logy. 2009. 87(7). 493-514. Available from:

Samuels M.A. The Brain — Heart Connection. Circulation. 2007, Jul 03. 116(1). 77-84. Available from:

Ruthirago D., Julayanont P., Tantrachot P., Kim J., Nugent K. Cardiac Arrhythmias and Abnormal Electrocardiograms after Acute Stroke. American Journal of the Medical Sciences. 2016, Jan. 351(1). 112-8. DOI:

Gopinath R., Ayya S.S. Neurogenic stress cardiomyopathy: What do we need to know. Annals of Cardiac Anaesthesia. 2018. 21(3). 228-34. Available from:;year=2018;volume=21;issue=3;spage=228;epage=234;aulast=Gopinath.

Hasanin A., Zakaria D., Allam A. Cardiac injury in severe head trauma: a review of literature. Journal of Neurology & Neuromedicine. 2016, Nov 26. 1(8). 41-3. Available from:

Lin X., Xu Z., Wang P., Xu Y., Zhang G. Role of PiCCO monitoring for the integrated management of neurogenic pulmonary edema following traumatic brain injury: A case report and literature review. Experimental and Therapeutic Medicine. 2016, Oct. 12(4). 2341-7. DOI: 10.3892/etm.2016.3615.

Riera M., Llompart-Pou J.A., Carrillo A., Blanco C. Head injury and inverted Takotsubo cardiomyopathy. Journal of Trauma. 2010, Jan. 68(1). E13-5. doi: 10.1097/TA.0b013e3181469d5b.

Bahloul M., Chaari A.N., Kallel H., Khabir A., Ayadi A., Charfeddine H. et al. Neurogenic pulmonary edema due to traumatic brain injury: evidence of cardiac dysfunction. American Journal of Critical Care. 2006, Sep. 15(5). 462-70. Available from:

Hüttemann E., Schelenz C., Chatzinikolaou K., Reinhart K. Left ventricular dysfunction in lethal severe brain injury: impact of transesophageal echocardiography on patient management. Intensive Care Medicine. 2002, Aug. 28(8). 1084-8. DOI: 10.1007/s00134-002-1355-x.

Prathep S., Sharma D., Hallman M., Joffe A., Krishnamoorthy V., Mackensen G.B. et al. Preliminary report on cardiac dysfunction after isolated traumatic brain injury. Critical Care Medicine. 2014, Jan. 42(1). 142-7. doi: 10.1097/CCM.0b013e318298a890.

Hasanin A., Kamal A., Amin S., Zakaria D., El Sayed R., Mahmoud K. et al. Incidence and outcome of cardiac injury in patients with severe head trauma. Scandinavian Journal of Trauma, Resuscitation & Emergency Medicine. 2016, Apr 27. 24. 58. doi: 10.1186/s13049-016-0246-z.

Serri K., El Rayes M., Giraldeau G., Williamson D., Bernard F. Traumatic brain injury is not associated with significant myocardial dysfunction: an observational pilot study. Scandinavian Journal of Trauma, Resuscitation & Emergency Medicine. 2016, Mar 16. 24. 31. doi: 10.1186/s13049-016-0217-4.

Finsterer J., Bersano A. Seizure-triggered Takotsubo syndrome rarely causes SUDEP. European Journal of Epilepsy. 2015, Sep. 31. 84-7. DOI:

Oomura M., Yamawaki T., Oe H., Moriwaki H., Miyashita K., Naritomi H. et al. Association of cardiomyopathy caused by autonomic nervous system impairment with the Miller Fisher syndrome. Journal of Neurology, Neurosurgery & Psychiatry. 2003. 74(5). 687-91. Available from:

Renjen P.N., Khanna L., Ahmed K. Reversible cardiomyopathy in Guillain-Barre syndrome. Journal of Association of Physicians India. 2014, Aug. 62(8). 734-6. Available from:

Anandan C., Khuder S.A., Koffman B.M. Prevalence of autonomic dysfunction in hospitalized patients with Guillain-Barré syndrome. Muscle & Nerve. 2017, Aug. 56(2). 331-3. doi: 10.1002/mus.25551.

Gravos A., Destounis A., Katsifa K., Tselioti P., Sakellaridis K., Grammatikopoulou V. et al. Reversible stress cardiomyopathy in Guillain-Barré syndrome: a case report. Journal of Medical Case Reports. 2019, May 20. 13. 150. doi: 10.1186/s13256-019-2085-9.

Bilotta F., Stazi E., Zlotnik A., Gruenbaum S.E., Rosa G. Neuroprotective Effects of Intravenous Anesthetics: A New Critical Perspective. Current Pharmaceutical Design. 2014. 20(34). 5469-75. Available from:

Nunes R.R., Duval Neto G.F., Garcia de Alencar J.C., Franco S.B., Quezado de Andrade N., Holanda Dumaresq D.M. et al. Anesthetics, cerebral protection and preconditioning. Revista Brasileira de Anestesiologia. 2013. 63(1). 119-28. Available from:

Fukuda S., Warner D.S. Cerebral protection. BJA: Bri-tish Journal of Anaesthesia. 2007, Jul. 99(1). 10-7. Available from:

Mirrakhimov A.E., Voore P., Halytskyy O., Khan M., Ali A.M. Propofol Infusion Syndrome in Adults: A Clinical Update. Critical Care Research & Practice. 2015, Apr 12. 2015. 260385. doi: 10.1155/2015/260385.

Gregory T., Smith M. Cardiovascular complications of brain injury. Continuing Education in Anaesthesia, Critical Care & Pain Journal. 2012. 12(2). 67-71. doi: 10.1093/bjaceaccp/mkr058.

Otterspoor L.C., Kalkman C.J., Cremer O.L. Update on the propofol infusion syndrome in ICU management of patients with head injury. Current Opinion in Anesthesiology. 2008, Oct. 21(5). 544-51. doi: 10.1097/ACO.0b013e32830f44fb.

Carney Т., Totten A.M., O’Reilly C., Ullman J.S., Hawryluk G.W.J., Bell M.J. et al. Guidelines for the Management of Severe Traumatic Brain Injury 4th Edition [Internet] Brain Trauma Foundation [published Sep 2016, cited 26 Jun, 2019] [244 pages] Available from:

Pomblum V.J., Korbmacher B., Cleveland S., Sunderdiek U., Klocke R.C., Schipk J.D. Cardiac stunning in the clinic: the full picture. Interactive CardioVascular and Thoracic Surgery. 2010. 10. 86-91. doi: 10.1510/icvts.2009.205666.

Scott T., Swanevelder J. Perioperative myocardial protection. Continuing Education in Anaesthesia Critical Care & Pain Journal. 2009, Jun. 9(3). 97-101. Available from:

Toller W.G., Kersten J.R., Pagel P.S., Warltier D.C. Ischemic preconditioning, myocardial stunning and anesthesia. Current Opinion in Anaesthesiology. 2000, Feb. 13(1). 35-40. Available from:,_myocardial_stunning.

González-Montero J., Brito R., Gajardo A.I.J., Rodrigo R. Myocardial reperfusion injury and oxidative stress: Therapeutic opportunities. World Journal of Cardiology. 2018, Sep 26. 2018. 10(9). 74-86. doi: 10.4330/wjc.v10.i9.74.

Kozhukhov S.M., Parkhomenko O.M. Sertseva nedostatnist zi zberezhenoiu fraktsiiu vykydu livoho shlunochka. Medytsyna nevidkladnykh staniv. 2016. 1(72). 126-30 [Ukrainian].

Vatutyn N.T., Taradyn H.H., Smyrnova A.S., El-Khatyb M.A., Hrytsenko Yu.P., Bort D.V. y dr. Syndrom takotsubo: sovremennoe sostoianye problemy. Obzor rekomendatsyi Assotsyatsyy serdechnoi nedostatochnosty Evropeiskoho obshchestva kardyolohov (ESC-HFA) 2016 [Internet] Praktychna anhiolohiia. 2016; spetsialne vydannia. 56-70. Available from: [Russian].

Sato H. Tako-tsubo-like left ventricular dysfunction due to multivessel coronary spasm. In: Kodama K., Haze K., Hori M. eds. Clinical Aspect of Myocardial Injury: From Ischemia to Heart Failure; Tokyo: Kagakuhyoronsha Publishing Co, 1990. 56-64 [Japanese].

Abe Y., Kondo M., Matsuoka R., Araki M., Dohyama K., Tanio H. Assessment of clinical features in transient left ventricular apical ballooning. Journal of the American College of Cardiology. 2003, Mar 05. 41(5). 737-42.

Bybee K.A., Kara T., Prasad A., Lerman A., Barsness G.W., Wright R.S. et al. Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction. Annals of Internal Medicine. 2004, Dec 07. 141(11). 858-65.

Maron B.J., Towbin J.A., Thiene G., Antzelevitch C., Corrado D., Arnett D. et al. Contemporary definitions and classification of the cardiomyopathies: an American Heart Association Scientific Statement from the Council on Clinical Cardiology, Heart Failure and Transplantation Committee; Quality of Care and Outcomes Research and Functional Genomics and Translational Biology Interdisciplinary Working Groups; and Council on Epidemiology and Prevention. Circulation. 2006, Apr 11. 113(14). 1807-16.

Prasad A., Lerman A., Rihal C.S. Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction. American Heart Journal. 2008, Mar. 155(3). 408-17. doi: 10.1016/j.ahj.2007.11.008.

Ghadri J.R., Wittstein I.S., Prasad A., Sharkey S., Dote K., Akashi Y.J. et al. International Expert Consensus Document on Takotsubo Syndrome (Part I): Clinical Characteristics, Diagnostic Criteria, and Pathophysiology. European Heart Journal. 2018, Jun 07. 39(22). 2032-46. Available from:

Ghadri J.R., Wittstein I.S., Prasad A., Sharkey S., Dote K., Akashi Y.J. et al. International Expert Consensus Document on Takotsubo Syndrome (Part II): Diagnostic Workup, Outcome, and Management. European Heart Journal. 2018, Jun 07. 39(22). 2047-62. Available from:


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