Stress-mediated cardiomyopathies are rare entities characterized by transient heart failure in the absence of obstructive coronary disease. It can be seen in central nervous disorders including intracerebral hemorrhage, ischemic stroke and epilepsy. Here we present a case of cardiac arrest and subsequent transient cardiomyopathy following mechanical thrombectomy in a patient with residual ischemic stroke involving left insular region.

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A 75-year-old woman presented with acute onset confusion and speech difficulty. Computed tomography (CT) and CT angiography of head showed an occlusion in the M2 branch of left middle cerebral artery (MCA). She received acute thrombolytics and underwent mechanical thrombectomy.  Shortly after arrival to the neurointensive care unit, patient went into cardiac arrest. After 7 minutes of CPR including 3 rounds of chest compressions and epinephrine, spontaneous circulation was returned. Electrocardiogram (ECG) showed atrial fibrillation and an immediate bedside echocardiogram revealed severe global hypokinesis with ejection-fraction of 20%. Subsequently, MRI brain demonstrated evolving infarction in the left insular cortex and temporal lobe. Repeat echocardiogram ten days post-arrest revealed resolution of ventricular hypokinesis and normal ejection-fraction of 65%.

Our patient suffered an acute left MCA-territory infarct likely in the setting of new onset atrial fibrillation. We propose that cardiac arrest following neurologic interventions was caused by stress-mediated cardiomyopathy in the setting of an acute infarction particularly involving the left insular region. This is supported by the fact that she did not have any history of cardiac problems. Though there have been rare reports of right-sided insular injury leading to cardiac autonomic derangements, cardiac arrest following left insular injury has never been previously reported. Further studies are warranted to confirm whether insular cortex (‘cardunculus’) infarction is an independent predictor of cardiac complications in such patients.