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CASE REPORT
Year : 2013  |  Volume : 23  |  Issue : 1  |  Page : 39-41

Radial strain: Harbinger of good news


1 Department of Medicine and Pharmacology, University of Messina, Messina, Italy
2 Aurora Cardiovascular Services, Aurora Sinai/Aurora St. Luke's Medical Centers, University of Wisconsin School of Medicine and Public Health, Milwaukee, Wisconsin, USA

Date of Web Publication10-Sep-2013

Correspondence Address:
Bijoy K Khandheria
Aurora Cardiovascular Services, 2801 W. Kinnickinnic River Parkway, #845, Milwaukee, WI 53215
USA
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Source of Support: There are no funding sources to disclose relative to this submission,, Conflict of Interest: The authors have no conflicts of interest to disclose.


DOI: 10.4103/2211-4122.117984

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  Abstract 

Introduction: We report the case of a 58-year-old woman with intracranial hemorrhage associated with stress-induced cardiomyopathy. Results: Left ventricular dysfunction was confined to midventricular segments, and manifested with transient anterolateral wall aneurysm. Although wall motion was severely impaired in the mid-segments, an almost preserved global midventricular radial strain forecasted rapid improvement of ventricular function. Conclusions: This case highlights how deformation imaging can help in clinical practice to interpret the subtle signs of recovery from left ventricular dysfunction.

Keywords: Echocardiography, midventricular dysfunction, radial strain, speckle tracking imaging, stress-induced -cardiomyopathy


How to cite this article:
Oreto L, Todaro MC, Tumuluri R, Gupta A, Khandheria BK. Radial strain: Harbinger of good news. J Cardiovasc Echography 2013;23:39-41

How to cite this URL:
Oreto L, Todaro MC, Tumuluri R, Gupta A, Khandheria BK. Radial strain: Harbinger of good news. J Cardiovasc Echography [serial online] 2013 [cited 2021 Oct 22];23:39-41. Available from: https://www.jcecho.org/text.asp?2013/23/1/39/117984


  Case Report Top


A 58-year-old woman was admitted one year ago to the neurointensive care unit of our hospital for sudden onset of intracerebral and subarachnoid hemorrhage of the right frontal lobe. She had a history of tobacco use and moderate alcohol abuse, hypertension and chronic obstructive pulmonary disease. Her surgical history included left lumpectomy for breast cancer, amputation of the third finger on the right hand and jaw surgery a few years ago. At admission her vital signs were within the normal range: blood pressure 140/87 mmHg, heart rate 71 beats per minute (bpm), respiratory rate 20 breaths per minute and oxygen saturation on ventilator 100%. She was awake and alert but lethargic. The electrocardiogram (ECG) at admission showed normal sinus rhythm (60 bpm) and possible septal necrosis. Right craniotomy for evacuation of the hemorrhage and clipping of right middle cerebral artery aneurysm were performed. Postoperatively, her neurological functions were intact. Troponin I levels showed a slight increase from 0.33 to 3.55 ng/mL during the first two days, and then decreased to 1.96 ng/mL on the third day postsurgery, and similar variations were seen for the levels of creatine kinase-MB fraction (from 4.0 to 11.5 to 4.3 μmol/L). ECG on the second day showed deep negative T waves in almost all leads with prolonged QTc interval [Figure 1]. Due to abnormal myocardial necrosis markers and ECG, a two-dimensional (2D) transthoracic echocardiogram was ordered, and revealed a normal left ventricular cavity size with hyperdynamic basal motion, akinesis of midventricular segments and nearly normal apical motion [Figure 2]. Left ventricular global systolic function was moderately decreased with left ventricular ejection fraction at 35% (normal values >55%). Clinical and echocardiographic features were consistent with stress-induced cardiomyopathy.
Figure 1: Electrocardiogram on second day post-right craniotomy for evacuation of hemorrhage and clipping of right middle cerebral artery aneurysm showing deep negative T waves in almost all leads with prolonged QTc interval (580 ms)

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Figure 2: Two-dimensional transthoracic echocardiography in the apical four-chamber view showing the left ventricle a) at end diastole and b) mid-systole. Basal and apical segments contract well in contrast to midventricular segments

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The next day, the patient underwent coronary angiography, which ruled out any coronary artery disease. However, the ventriculogram surprisingly revealed an aneurysmatic anterior wall [Figure 3], which then was characterized by another transthoracic echocardiogram as an anteroseptal wall aneurysm with near-normal motion of the other segments [Figure 4]. Global radial strain was calculated and, despite seriously compromised midventricular anteroseptal motion, midventricular-averaged radial strain was at the lower end of normal range (i.e. 16%).
Figure 3: Left ventriculogram showing systolic anterior wall aneurysm

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Figure 4: Two-dimensional transthoracic echocardiography in the apical long-axis view showing anteroseptal wall aneurysm with nearly normal motion of the other segments in a) end diastole and b) mid-systole

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As predicted by the global radial strain in the previous examination, another transthoracic echocardiogram performed three weeks later documented the complete resolution of wall motion abnormalities [Figure 5]a and b, with completely normal radial strain values [Figure 5]c.
Figure 5: Two-dimensional (2D) transthoracic echocardiogram in the apical long-axis view showing complete resolution of wall motion abnormalities at a) end diastole and b) mid-systole. c) shows radial strain of midventricular segments. On the left, a short-axis view of the mid-left ventricle is shown, and a 2D speckle tracking technique is used to obtain the curves representing radial deformation of each wall segment (right). The averaged global strain is 57% (represented by white curve)

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  Discussion Top


Isolated left ventricular midventricular dyskinesia is a rare variant of stress-induced cardiomyopathy, [1] although it has been described in association with cerebral injuries. [2] Left ventricular mechanics in stress-induced cardiomyopathy have not been well defined, although some data about the longitudinal and radial strain are available. [3]


  Conclusions Top


Our case highlights the importance of global radial strain as a predictor of myocardial wall motion improvement, even when 2D transthoracic echocardiogram did not forecast the improvement.


  Acknowledgments Top


The authors gratefully acknowledge Barbara Danek, Joe Grundle and Katie Klein of Aurora Cardiovascular Services for editorial preparation of the manuscript, and Brian Miller and Brian Schurrer of Aurora Sinai Medical Center for their help with figures.

 
  References Top

1.Hurst RT, Askew JW, Reuss CS, Lee RW, Sweeney JP, Fortuin FD, et al. Transient midventricular ballooning syndrome: A new variant. J Am Coll Cardiol 2006;48:579-83.  Back to cited text no. 1
[PUBMED]    
2.Cardin C, Roncalli J, Lairez O, Austruy J, Elbaz M, Carrie D, et al. Subarachnoid haemorrhage associated with midventricular Tako-Tsubo syndrome. Int J Cardiol 2011;146:e46-8.  Back to cited text no. 2
[PUBMED]    
3.Heggemann F, Weiss C, Hamm K, Kaden J, Süselbeck T, Papavassiliu T, et al. Global and regional myocardial function quantification by two-dimensional strain in Takotsubo cardiomyopathy. Eur J Echocardiogr 2009;10:760-4.  Back to cited text no. 3
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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