Cardiac Complication Following Subarachnoid Hemorrhage

Document Type : Review Article


1 Cardiologist,Cardiac Department, Mashhad University of Medical Sciences, Mashhad, Iran

2 Neuroradiologist, Interventional Neuroradiology Department, Hospital of Rothschild Roundation, Paris 75019, France

3 Endovascular Neurosurgeon, Department of Neurosurgery, Ghaem Hospital, Mashhad University of Medical Sciences,Mashhad,Iran

4 Neurosurgeon, Department of Neurosurgery, Ghaem Hospital, Mashhad University of Medical Sciences,Mashhad


Besides its severe neurological injuries, spontaneous subarachnoid hemorrhage (SAH) commonly causes cardiac complications. These complications could include three different aspects of cardiac diseases, that is, electrocardiographic abnormalities, myocardial injuries, and left ventricular dysfunction. These complications not only may lead to misdiagnosis of SAH as myocardial infarction, but also it may complicate the management of SAH. In this review, we described all cardiac complications during SAH and explained the appropriate monitoring and management of these problems


1.             Hop JW, Rinkel GJ, Algra A, van Gijn J. Case-fatality rates and functional outcome after subarachnoid hemorrhage: a systematic review. Stroke. 1997;28(3):660-4.
2.             Burch GE, Meyers R, Abildskov JA. A new electrocardiographic pattern observed in cerebrovascular accidents. Circulation. 1954;9(5):719-23.
3.             Chen Z, Venkat P, Seyfried D, Chopp M, Yan T, Chen J. Brain-Heart Interaction: Cardiac Complications After Stroke. Circ Res. 2017;121(4):451-68.
4.             van der Bilt IA, Hasan D, Vandertop WP, Wilde AA, Algra A, Visser FC, et al. Impact of cardiac complications on outcome after aneurysmal subarachnoid hemorrhage: a meta-analysis. Neurology. 2009;72(7):635-42.
5.             Zhang L, Qi S. Electrocardiographic Abnormalities Predict Adverse Clinical Outcomes in Patients with Subarachnoid Hemorrhage. J Stroke Cerebrovasc Dis. 2016;25(11):2653-9.
6.             Davis TP, Alexander J, Lesch M. Electrocardiographic changes associated with acute cerebrovascular disease: a clinical review. Prog Cardiovasc Dis. 1993;36(3):245-60.
7.             Urbaniak K, Merchant AI, Amin-Hanjani S, Roitberg B. Cardiac complications after aneurysmal subarachnoid hemorrhage. Surg Neurol. 2007;67(1):21-8; discussion 8-9.
8.             Brouwers PJ, Westenberg HG, Van Gijn J. Noradrenaline concentrations and electrocardiographic abnormalities after aneurysmal subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry. 1995;58(5):614-7.
9.             Sommargren CE. Electrocardiographic abnormalities in patients with subarachnoid hemorrhage. Am J Crit Care. 2002;11(1):48-56.
10.          Chatterjee S. ECG Changes in Subarachnoid Haemorrhage: A Synopsis. Neth Heart J. 2011;19(1):31-4.
11.          Acharya S, Chatterjee S, Kumar P, Bhattacharjee M, Chaudhuri S, Chaudhuri S. Induction of G1 arrest in glioma cells by T11TS is associated with upregulation of Cip1/Kip1 and concurrent downregulation of cyclin D (1 and 3). Anticancer Drugs. 2010;21(1):53-64.
12.          Kuroiwa T, Morita H, Tanabe H, Ohta T. Significance of ST segment elevation in electrocardiograms in patients with ruptured cerebral aneurysms. Acta neurochirurgica. 1995;133(3-4):141-6.
13.          Di Pasquale G, Pinelli G, Andreoli A, Manini G, Grazi P, Tognetti F. Holter detection of cardiac arrhythmias in intracranial subarachnoid hemorrhage. Am J Cardiol. 1987;59(6):596-600.
14.          Frontera JA, Parra A, Shimbo D, Fernandez A, Schmidt JM, Peter P, et al. Cardiac arrhythmias after subarachnoid hemorrhage: risk factors and impact on outcome. Cerebrovasc Dis. 2008;26(1):71-8.
15.          Bruder N, Rabinstein A, Participants in the International Multi-Disciplinary Consensus Conference on the Critical Care Management of Subarachnoid H. Cardiovascular and pulmonary complications of aneurysmal subarachnoid hemorrhage. Neurocrit Care. 2011;15(2):257-69.
16.          Frangiskakis JM, Hravnak M, Crago EA, Tanabe M, Kip KE, Gorcsan J, 3rd, et al. Ventricular arrhythmia risk after subarachnoid hemorrhage. Neurocrit Care. 2009;10(3):287-94.
17.          Mayer SA, Lin J, Homma S, Solomon RA, Lennihan L, Sherman D, et al. Myocardial injury and left ventricular performance after subarachnoid hemorrhage. Stroke. 1999;30(4):780-6.
18.          Ay H, Arsava EM, Saribas O. Creatine kinase-MB elevation after stroke is not cardiac in origin: comparison with troponin T levels. Stroke. 2002;33(1):286-9.
19.          Naidech AM, Kreiter KT, Janjua N, Ostapkovich ND, Parra A, Commichau C, et al. Cardiac troponin elevation, cardiovascular morbidity, and outcome after subarachnoid hemorrhage. Circulation. 2005;112(18):2851-6.
20.          Yarlagadda S, Rajendran P, Miss JC, Banki NM, Kopelnik A, Wu AH, et al. Cardiovascular predictors of in-patient mortality after subarachnoid hemorrhage. Neurocrit Care. 2006;5(2):102-7.
21.          Oras J, Grivans C, Bartley A, Rydenhag B, Ricksten SE, Seeman-Lodding H. Elevated high-sensitive troponin T on admission is an indicator of poor long-term outcome in patients with subarachnoid haemorrhage: a prospective observational study. Crit Care. 2016;20:11.
22.          Banki N, Kopelnik A, Tung P, Lawton MT, Gress D, Drew B, et al. Prospective analysis of prevalence, distribution, and rate of recovery of left ventricular systolic dysfunction in patients with subarachnoid hemorrhage. J Neurosurg. 2006;105(1):15-20.
23.          Zaroff JG, Rordorf GA, Titus JS, Newell JB, Nowak NJ, Torchiana DF, et al. Regional myocardial perfusion after experimental subarachnoid hemorrhage. Stroke. 2000;31(5):1136-43.
24.          Rinkel GJ. Medical management of patients with aneurysmal subarachnoid haemorrhage. Int J Stroke. 2008;3(3):193-204.
25.          Abd TT, Hayek S, Cheng JW, Samuels OB, Wittstein IS, Lerakis S. Incidence and clinical characteristics of takotsubo cardiomyopathy post-aneurysmal subarachnoid hemorrhage. Int J Cardiol. 2014;176(3):1362-4.
26.          Tsuchihashi K, Ueshima K, Uchida T, Oh-mura N, Kimura K, Owa M, et al. Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. Angina Pectoris-Myocardial Infarction Investigations in Japan. J Am Coll Cardiol. 2001;38(1):11-8.
27.          Garg R, Bar B. Systemic Complications Following Aneurysmal Subarachnoid Hemorrhage. Curr Neurol Neurosci Rep. 2017;17(1):7.
28.          Bulsara KR, McGirt MJ, Liao L, Villavicencio AT, Borel C, Alexander MJ, et al. Use of the peak troponin value to differentiate myocardial infarction from reversible neurogenic left ventricular dysfunction associated with aneurysmal subarachnoid hemorrhage. J Neurosurg. 2003;98(3):524-8.
29.          White M, Wiechmann RJ, Roden RL, Hagan MB, Wollmering MM, Port JD, et al. Cardiac beta-adrenergic neuroeffector systems in acute myocardial dysfunction related to brain injury. Evidence for catecholamine-mediated myocardial damage. Circulation. 1995;92(8):2183-9.
30.          Dhar R, Diringer MN. The burden of the systemic inflammatory response predicts vasospasm and outcome after subarachnoid hemorrhage. Neurocrit Care. 2008;8(3):404-12.
31.          van der Bilt IA, Vendeville JP, van de Hoef TP, Begieneman MP, Lagrand WK, Kros JM, et al. Myocarditis in patients with subarachnoid hemorrhage: A histopathologic study. J Crit Care. 2016;32:196-200.
32.          Pinnamaneni S, Dutta T, Melcer J, Aronow WS. Neurogenic stress cardiomyopathy associated with subarachnoid hemorrhage. Future Cardiol. 2015;11(1):77-87.
33.          Diringer MN, Bleck TP, Claude Hemphill J, 3rd, Menon D, Shutter L, Vespa P, et al. Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society's Multidisciplinary Consensus Conference. Neurocrit Care. 2011;15(2):211-40.
34.          Mazzeo AT, Micalizzi A, Mascia L, Scicolone A, Siracusano L. Brain-heart crosstalk: the many faces of stress-related cardiomyopathy syndromes in anaesthesia and intensive care. Br J Anaesth. 2014;112(5):803-15.
35.          Abdelmawgoud A, Brown CJ, Sui X, Fonarow GC, Kokkinos PF, Bittner V, et al. Relationship of Physical Activity and Healthy Eating with Mortality and Incident Heart Failure among Community-Dwelling Older Adults with Normal Body Mass Index. ESC Heart Fail. 2015;2(1):20-4.
36.          van der Velden LB, Otterspoor LC, Schultze Kool LJ, Biessels GJ, Verheugt FW. Acute myocardial infarction complicating subarachnoid haemorrhage. Neth Heart J. 2009;17(7-8):284-7.
37.          Diringer MN, Zazulia AR. Aneurysmal Subarachnoid Hemorrhage: Strategies for Preventing Vasospasm in the Intensive Care Unit. Semin Respir Crit Care Med. 2017;38(6):760-7.
38.          Liang CW, Chen R, Macri E, Naval N. Preadmission beta-blockers are associated with decreased incidence of neurogenic stunned myocardium in aneurysmal subarachnoid hemorrhage. J Stroke Cerebrovasc Dis. 2013;22(5):601-7.
39.          Chalouhi N, Daou B, Okabe T, Starke RM, Dalyai R, Bovenzi CD, et al. Beta-blocker therapy and impact on outcome after aneurysmal subarachnoid hemorrhage: a cohort study. J Neurosurg. 2016;125(3):730-6.
40.          Neil-Dwyer G, Walter P, Cruickshank JM, Doshi B, O'Gorman P. Effect of propranolol and phentolamine on myocardial necrosis after subarachnoid haemorrhage. Br Med J. 1978;2(6143):990-2.
41.          Kawaguchi M, Utada K, Yoshitani K, Uchino H, Takeda Y, Masui K, et al. Effects of a short-acting [beta]1 receptor antagonist landiolol on hemodynamics and tissue injury markers in patients with subarachnoid hemorrhage undergoing intracranial aneurysm surgery. J Neurosurg Anesthesiol. 2010;22(3):230-9.
42.          Rondeau N, Cinotti R, Rozec B, Roquilly A, Floch H, Groleau N, et al. Dobutamine-induced high cardiac index did not prevent vasospasm in subarachnoid hemorrhage patients: a randomized controlled pilot study. Neurocrit Care. 2012;17(2):183-90.
43.          Deehan SC, Grant IS. Haemodynamic changes in neurogenic pulmonary oedema: effect of dobutamine. Intensive Care Med. 1996;22(7):672-6.
44.          Levy ML, Rabb CH, Zelman V, Giannotta SL. Cardiac performance enhancement from dobutamine in patients refractory to hypervolemic therapy for cerebral vasospasm. J Neurosurg. 1993;79(4):494-9.
45.          Saito R, Takahashi T, Noshita N, Narisawa A, Negi K, Takei K, et al. Takotsubo cardiomyopathy induced by dobutamine infusion during hypertensive therapy for symptomatic vasospasm after subarachnoid hemorrhage -case report. Neurol Med Chir (Tokyo). 2010;50(5):393-5.
46.          Naidech A, Du Y, Kreiter KT, Parra A, Fitzsimmons BF, Lavine SD, et al. Dobutamine versus milrinone after subarachnoid hemorrhage. Neurosurgery. 2005;56(1):21-6l discussion 6-7.
47.          Busani S, Rinaldi L, Severino C, Cobelli M, Pasetto A, Girardis M. Levosimendan in cardiac failure after subarachnoid hemorrhage. J Trauma. 2010;68(5):E108-10.
48.          Ducruet AF, Albuquerque FC, Crowley RW, Williamson R, Forseth J, McDougall CG. Balloon-pump counterpulsation for management of severe cardiac dysfunction after aneurysmal subarachnoid hemorrhage. World Neurosurg. 2013;80(6):e347-52.
49.          Lylyk P, Vila JF, Miranda C, Ferrario A, Romero R, Cohen JE. Partial aortic obstruction improves cerebral perfusion and clinical symptoms in patients with symptomatic vasospasm. Neurol Res. 2005;27 Suppl 1:S129-35.
50.          Appelboom G, Strozyk D, Hwang BY, Prowda J, Badjatia N, Helbok R, et al. Bedside use of a dual aortic balloon occlusion for the treatment of cerebral vasospasm. Neurocrit Care. 2010;13(3):385-8.
51.          Rahal JP, Malek AM, Heilman CB. Intra-aortic balloon pump counterpulsation in aneurysmal subarachnoid hemorrhage. World Neurosurg. 2013;80(6):e203-7.