Diffuse coronary artery vasospasm in a patient with subarachnoid hemorrhage: A case report

Background: Coronary artery vasospasm (CAV) is a reversible, transient form of vasoconstriction with clinical manifestations ranging from stable angina to acute coronary syndromes (ACS). Vasospasm of epicardial coronary arteries or associated micro-vasculature can lead to total or subtotal occlusion and has been demonstrated in nearly 50% of patients undergoing angiography for suspected ACS. The mechanism for CAV has been described in literature, but in a subgroup of patients presenting with intracranial hemorrhage, it appears to be multifactorial. These patients tend to have electrocardiographic changes, elevation of cardiac biomarkers of injury and neurogenic stress cardiomyopathy.

Case summary: A 44-year-old woman presented with severe headaches and tonic-clonic seizures. She was found to have diffuse subarachnoid hemorrhage (SAH) requiring ventricular drain placement, coil embolization and induced hypertension. She subsequently developed chest pain with ST elevations in anterior precordial leads, elevated cardiac enzymes and apical ballooning with left ventricular ejection fraction of 35% on transthoracic echocardiogram. Coronary angiogram revealed severe diffuse triple vessel stenoses secondary to CAV seen distally. Subsequent cardiac MRI notable for apical non-viability and scar formation.

Conclusion: This case highlights a unique etiology of acute myocardial infarction in a patient with SAH leading to ST elevations, diffuse triple vessel CAV and apical scar.

Keywords: Acute coronary syndrome; Case report; Cerebral vasospasm; Coronary artery vasospasm; ST-elevation myocardial infarction; Stress induced cardiomyopathy; Subarachnoid hemorrhage.