we report the case of a 58-year - old woman with intracranial hemorrhage associated with stress - induced cardiomyopathy .
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 .
this case highlights how deformation imaging can help in clinical practice to interpret the subtle signs of recovery from left ventricular dysfunction .
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% .
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 .
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
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% ) .
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 ) 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 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% ) .
left ventriculogram showing systolic anterior wall aneurysm 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 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 5a and b ] , with completely normal radial strain values [ figure 5c ] .
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 .
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 )
isolated left ventricular midventricular dyskinesia is a rare variant of stress - induced cardiomyopathy , although it has been described in association with cerebral injuries . left ventricular mechanics in stress - induced cardiomyopathy
have not been well defined , although some data about the longitudinal and radial strain are available .
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 .
 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 . 
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