Critical Care Neurocardiology

Journal of Internal Medicine and Emergency Research ISSN: 2582-7367

Rao M S, et al, 2021- Intern Med Emerg Res Research Article

Critical Care Neurocardiology 1KIMS Hospitals, Hyderabad, Telangana, India 1* 2 S Manimala Rao , Vivek Balijepalli 2AIG Hospital Gachibowli, Hyderabad, Telangana, India

*Corresponding Author: Prof S Abstract Manimala Rao M.D,D.A Anesthesiologist And Critical Care Physician, Director Neurocardiology is a term which was coined in the early 80s. It is very Medical Education And Academics, Kims apt to use this word in critical care when one manages patients who Hospitals ,Hyderabad, Telangana, India. are admitted to critical care and develop both cardiac and Accepted Date: 05-11-2021 neurological problems simultaneously, one leading to the other. Published Date: 06-11-2021 Though they are viewed separately by the concerned specialists they Copyright© 2021 by Rao M S, et al. All are managed simultaneously in the ICU by the critical care physician. rights reserved. This is an open access We present two cases in this area The pathophysiology management article distributed under the terms of the is discussed. Creative Commons Attribution License, which permits unrestricted use, Keywords: Neurocardiology; Critical care; Diabetes. distribution, and reproduction in any medium, provided the original author and source are credited. Introduction

Cardiac disturbances are quite frequent in a importance of brain–heart interactions from stroke patient be it arrhythmia or LV the 80s onwards. However, many do not view dysfunction. It is becoming quite common to them together for management. These observe the heart and brain interaction in the relationships in terms of physiological, ICU. Critical care at its core takes into clinical and management issues daily are of consideration the human body in its entirety. utmost importance in critical care. So, the Hence the clinical management of the brain questions are, can we consider the term and heart disorders cannot be isolated. The Neurocardiology in critical care on a daily care of neurologic patient is influenced by basis? What are the interactions between the cardiac diseases, and likewise neurological brain and the heart and what is the concerned consideration is essential in many types of pathophysiology? How does it influence in heart diseases. Cardiologists and Neurologists the management and outcomes of patients? view heart and brain alone respectively and In the setting of Critical care, time and proper ignore the other. There is a lot of literature decision making is a crucial factor. How with evidence regarding the hemodynamic & intracranial dynamic

Rao M S | Volume 2; Issue 1 (2021) | Mapsci-JIMER-2(1)-018 | Research Article Citation: Rao M S, Balijepalli V. Critical Care Neurocardiology. J Intern Med Emerg Res. 2021;2(1):1-9. DOI: https://doi.org/10.37191/Mapsci-2582-7367-2(1)-018 monitoring helps to determine the immediate Patient had sudden onset, left upper limb & and long-term management of the patient lower limb weakness associated with slurring and how it influences the outcome will be of speech & deviation of angle of mouth to the discussed. We present here a series of two right side since 1 day. Known alcoholic. cases which clearly depicted the alterations in Patient took treatment at a local hospital for the neuro-cardiac axis to reiterate the the above complaints. During his evaluation, importance of neurocardiology once again in he was found to have Antero septal MI, for the critical care setting. which he was started on antiplatelets and betablockers and referred to tertiary center Case 1 for further evaluation and management. 47-year-old male presented with h/o dry Patient vitals are given in Table 1. cough since 10 days.

Clinical Examination Vitals 1. Conscious, oriented 2. HR – 120/min 3. BP – 100/60 mmHg 4. RR- 24/min 5. SPO2 – 88 % on room air 6. CVS – S1,S2 + 7. RS - BAE +, Crepts + 8. P/A – Soft 9. CNS • GCS – 15/15 • Pupils – B/L reacting to light • Power - Left UL 0/5 & Left LL 0/5 and Right UL and LL 5/5 respectively

Table 1: Case 1 Clinical Examination.

Necessary investigations were done for the above patient. Investigations given in Table 2.

Investigations 1. CBP 10. Cl- - 98.2 2. Hb – 13.9 11. GRBS– 247 mg/dL

3. TLC – 11,400 12. HbA1c – 12.9 4. Platelets – 2 lakhs 13. Coagulation profile 5. Blood urea – 39 14. PT – 15.8/12.9 6. S. creatinine – 0.8 15. INR – 1.2 7. Electrolytes 16. APTT – 26/30 8. Na+ - 137 17. TSH – WNL 9. K+ - 4.2 18. Lipid Profile- WNL Table 2: Case 1 Investigations

Figure 1: ECG shows Antero-septal Wall MI.

Figure 2: Right Lower zone consolidation & Pulmonary edema.

Figure 3: 2D Echo - Large LV clot measuring 2.1 x 2.9cm RWMA involving the septum & Apex hypokinetic EF approx. 30%, Dilated LV Severe LV dysfunction.

Figure 4: Large Right MCA Infarct.

Patient was found to have Antero septal MI. started but later changed to 3 percent NaCl. 2D Echo showed a large LV clot and RWMA Initially, patient developed worsening of with severe LV dysfunction. X-ray revealed symptoms and increase in hypotension & was pulmonary edema with right lower zone started on vasopressor support with pneumonia. MRI brain done revealed large noradrenaline and dobutamine. Later patient MCA territory infarction. condition showed improvement and was Treatment was initiated with empirical weaned off noradrenaline & dobutamine antibiotics for Right lower lobe pneumonia. infusion. For severe LV dysfunction, Inotropic support Repeat Echo–revealed mild improvement (Dobutamine), frusemide & Aldactone. with EF of 30 to 35%. Repeat CT brain showed Anticoagulation & antiplatelets. ACE- mild hemorrhagic transformation inside the Inhibitors and Statins. Mannitol was initially existing infarct.

Figure 5: Mild hemorrhagic transformation inside the existing infarct.

During treatment, patient recovered from positive pressure ventilation) was instituted pulmonary edema and pneumonia. Patient in view of the florid pulmonary edema. showed improvement in motor power on left Patient had dyselectrolemia due to long term side with power of Left upper limb–2/5 and diuretic use. Patient had frequent ventricular left lower limb–3/5. Patient also had Recovery ectopics. CT angiogram revealed pulmonary of speech. Later patient shifted out of ICU and thrombo-embolism. There was severe PAH, subsequently discharged. In this difficult proBNP was 8749 and chest Xray showed clinical scenario coronary angiogram was not marked pulmonary oedema. Patient planned as the time delay was already existing developed mild weakness in the left upper and also patient had neurological problem. and lower limbs and the CT scan revealed very minimal hemorrhagic infarct. However, Case 2 aspirin and statins were continued, and cautious ant platelet medication usage A 52-year-old female, a known diabetic and a advocated. Slowly patient improved but case of dilated cardiomyopathy (DCMP) advised about her seriousness of her presented with acute heart failure. She was condition and to keep diabetes under good treated for heart failure with furosemide, control and to take medication regularly. dobutamine and BIPAP (non-invasive

Clinical Examination Vitals Investigations 1. Patient conscious oriented CBP – WNL 2. PR – 108/min Na – 122.80 3. BP – 80/60 mmHg K – 3.59 4. SPO2 – 80 % on RA Cl – 84 5. Systemic Examination Pro BNP - 8749 6. RS – B/L AE + 7. CVS: S1 S2 + 8. P/A – Soft Table 3: Clinical Examination and Investigations.

Figure 6: Marked Pulmonary Edema. Rao M S | Volume 2; Issue 1 (2021) | Mapsci-JIMER-2(1)-018 | Research Article Citation: Rao M S, Balijepalli V. Critical Care Neurocardiology. J Intern Med Emerg Res. 2021;2(1):1-9. DOI: https://doi.org/10.37191/Mapsci-2582-7367-2(1)-018

Figure 7: Decrease in Pleural Effusion & Cardiomegaly.

Figure 8: Monomorphic VPC’s – Due to Dyselectrolytemia.

Figure 9: CT pulmonary angiogram. PTE in the segmental branch of the right inferior lobar artery. Moderate Right Pleural effusion & mild left pleural effusion.

Figure 10: X ray after patient improvement.

Patient’s condition improved with two organs has led to analyze the various conservative management. Pulmonary edema clinical dilemmas [4]. The neurocardiac axis cleared on X ray. Dyselectrolytemia was links the cardiovascular system to corrected. Patient discharged with stable physiological problems like arrhythmia, vitals with advice regarding her heart epilepsy and stoke. The brain controls the condition and need for heart transplant. heart rate through balance between the sympathetic and parasympathetic nervous Discussion system. A clear and distinct balance is required between these two systems for Neurocardiology is a term coined to study the pathophysiological aspects of cardiovascular neurophysiological and neuroanatomical system. An imbalance may happen due to aspects of cardiology specially including the hormones levels, stress, lifestyle and injury neurological origins of cardiac disease. In 1985 [5]. It originates from the brain cortex and Netelson described the intra disciplinary area descends via hypothalamus and brain stem to terming neurocardiology which examines the onward journey to spinal cord from where all interactions between the cardiovascular and signals are transferred to the heart. The heart autonomic nervous system in receives its neural inputs from the pathophysiological states [1]. There are large parasympathetic ganglion and the lateral grey number of clinical entities namely the column of spinal cord. hypoxic brain damage, neurogenic stress The integration is not well articulated in cardiomyopathy, cerebral embolism, teaching in the respective Superspeciality. encephalitis, which have cardiovascular The doctors are more likely to think in a findings in patients with primary neurological tubular vision pertaining to their own disease [2]. It is well recorded that one in six specialty. Critical care specialists work in a strokes is caused by cardiogenic embolism [3]. wider arena so the problems considering The fundamental of understanding is the part neurocardiology should be well understood played by the nervous system by linking these

Rao M S | Volume 2; Issue 1 (2021) | Mapsci-JIMER-2(1)-018 | Research Article Citation: Rao M S, Balijepalli V. Critical Care Neurocardiology. J Intern Med Emerg Res. 2021;2(1):1-9. DOI: https://doi.org/10.37191/Mapsci-2582-7367-2(1)-018 and taught in todays practice so that correct hypotension in in this disease was thought to care is imparted at the right time. be due to use of levodopa and some other Stress whether acute or chronic can lead to causes. Instead, the patients with PD have an imbalance between these two nervous clear evidence of baroreflex failure and loss of systems and lead to alterations in the sympathetic innervations [8]. cardiovascular physiology. Stroke accelerates Cardiovascular disease is traditionally related the neurocardiac axis leading to sudden to well known risk factors namely death. It was shown in a study that loss of dyslipidemia, smoking, hypertension and hypothalamic and medullary integration at diabetes. More recently stress anxiety and the mid brain. This in turn resulted in the depression are proposed as risk factors activation of parasympathetic system leading including heart failure. It has been reviewed to sudden asystole and death after a stroke. regarding the evidence on the interactions Catecholamine medications have been used between cardiovascular and nervous systems to mitigate these affects [6]. focusing on how the CNS is involved in the Epilepsy may not cause death but the pathogenesis of cardiovascular disease. This imbalance in the neurocardiac axis can lead to knowledge makes the doctor to develop sympathetic over activity and lead to better strategies to treat patients in a holistic ventricular tachycardia or fibrillation. manner [9]. In our second case it was clearly Emotions and their effects some time baffle shown this aspect. everyone. The body homeostasis is The Takotsubo cardiomyopathy is often maintained through baroreceptors. The considered autochlonus to heart although the imbalance in the neurocardiac axis can lead to primary problem may not be in the heart alterations in the baroreceptor activity and muscle itself. Instead, similar to several there by leading to deleterious effects. Takotsubo like pathologies are seen in acute Heart-brain interactions can be referred as neurological disease. It may reflect the neurocardiology or cardioneurology as the capacity of nervous system to injure the heart. case may be as which organ is first affected Clinical and laboratory evidence shows that leading to the others involvement. In an cardiac structural damage can happen in the editorial way back in 1987 Sherman et al. have presence of normal heart in the context of very nicely depicted the various problems one stroke, seizures and traumatic brain injury faces dealing with the two organ interactions [10]. The first case presentation shows this [7]. aspect. Neurocardiology is the understanding that the body is interconnected and weave in and Conclusion out of other systems. When training within one specialty, the doctors are more likely to The heart and brain go hand in hand. associate patients' symptoms to their own Understanding the pathophysiology of field. neurocardiac axis in depth is the mantra Symptoms of abnormal autonomic nervous Cardiology and neurology are both super- system function occur commonly in specialties. The critical care physician should Parkinson’s Disease (PD) Orthostatic be able to balance it well, understanding both

Rao M S | Volume 2; Issue 1 (2021) | Mapsci-JIMER-2(1)-018 | Research Article Citation: Rao M S, Balijepalli V. Critical Care Neurocardiology. J Intern Med Emerg Res. 2021;2(1):1-9. DOI: https://doi.org/10.37191/Mapsci-2582-7367-2(1)-018 the differences as well as similarities. yield better results in the long run. Monitoring should be invasive and beat to Management of these patients is not easy but beat. Both organs require good blood sugar understanding each individual case will controls. The blood pressure control is reduce the mortality and morbidity. slightly different one requiring little higher and other almost normal. Usage of nitrates is Conflict of Interest not beneficial in neuro whereas it may be mandatory in cardiac. Use of ET CO2 and The authors report no relationships that ONSD (optic nerve sheath diameter) could be construed as a conflict of interest. Monitoring is extremely helpful particularly from neurological aspect along with invasive Acknowledgement monitoring. The ET CO2 monitoring is also useful for the cardiac problem too. Trying to We are thankful and grateful for our critical keep it towards normal is beneficial for both care team at Yashoda Hospital Somajiguda the organs. Hyderabad 2018 and also thank the Depending on the clinical criterion and administrators for giving us the opportunity understanding which organ involved first and and encourage publications. which organ is causing more damage can

References

1. Natelson BH. Neurocardiology: an interdisciplinary area for the 80s. Arch Neurol. 1985;42(2):178-84. PubMed 2. Louis R Caplan; J Willis Hurst; Marc I Chimowitz. Clinical Neurocardiology. Tex Heart Inst J. 1999 p324. CrossRef 3. Force CE. Cardiogenic brain embolism. Arch Neurol. 1986;43:71-84.PubMed | CrossRef 4. Fallen EL. Hidden rhythms in the heart rate record: a primer on neurocardiology. Clin Invest Med. 2000 ;23(6):339-46. PubMed 5. Pereira VH, Cerqueira JJ, Palha JA, Sousa N. Stressed brain, diseased heart: a review on the pathophysiologic mechanisms of neurocardiology. Int J Cardiol. 2013;166(1):30-7. PubMed | CrossRef 6. Davis AM, Natelson BH. Brain-heart interactions. The neurocardiology of arrhythmia and sudden cardiac death. Tex Heart Inst J. 1993;20(3):158. PubMed 7. Sherman DG, Hart RG, Shi F. Heart-brain interactions: neurocardiology or cardioneurology comes of age. Mayo Clin Proc. 1987;62(12):1158-60. PubMed 8. Goldstein DS. Dysautonomia in Parkinson's disease: neurocardiological abnormalities. Lancet Neurol. 2003;2(11):669-76. PubMed 9. Pereira VH, Cerqueira JJ, Palha JA, Sousa N. Stressed brain, diseased heart: a review on the pathophysiologic mechanisms of neurocardiology. Int J Cardiol. 2013;166(1):30-7. PubMed | CrossRef 10. Marafioti V, Turri G, Carbone V, Monaco S. Association of prolonged QTc interval with Takotsubo cardiomyopathy: A neurocardiac syndrome inside the mystery of the insula of Reil. Clin Cardiol. 2018;41(4):551- 5. PubMed | CrossRef