PMC8381246_01
6-lead monitor ECG (A) with ST-elevation in the inferolateral leads I,II,III,aVF (arrows) and ST depression in aVR (asterix). Coronary angiogram showing right coronary artery (B) with significant stenosis of the mid section of the right coronary artery (arrow) and coronary atheromatosis with not significant coronary artery disease of the left circumflex- and left anterior artery (C).
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F1
The provided print of 6-lead electrocardiogram (ECG) monitor strip showed inferolateral STEMI (Figure 1A). CAG showed mild (50%) stenosis of the mid left anterior descending artery and a significant (70%) stenosis of the right coronary artery (RCA) (Figures 1B,C).
Left ventricular ventriculography (A-D). In normal diastole (A), with typical apical ballooning and contraction of only the basal parts of the ventricle (B). Control angiogram after readmission 7 days later (C), showing different morphologies with mid-section hypercontraction and apical sparing (D). See also Supplementary Data Clips 1, 2.
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F2
Ventriculography revealed apical ballooning (Figures 2A,B) with a decreased left ventricular ejection fraction (LVEF) of 33%. TTS with a different morphology than at first presentation (Figures 2C,D). This was confirmed by transesophageal echocardiography (TEE).
Brain MRI (A-D). (A) Axial fluid-attenuated inversion recovery (FLAIR) MRI image shows a well-demarcated, hyperintense lesion in the left posterolateral part of the medulla oblongata (arrow). (B) Axial diffusion-weighted imaging (DWI) shows restriction of diffusion in this lesion (arrow). (C) Sagittal FLAIR MRI image shows a nodular hyperintensity in the right frontal lobe (arrow). (D) Sagittal short tau inversion recovery (STIR) image shows a hyperintense lesion in the cervical medulla at C4 (arrow).
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F3
Brain magnetic resonance imaging (MRI) showed a well-demarcated, oval-shaped T2 hyperintense lesion with diffusion restriction in the left cerebellar peduncle extending to the posterolateral part of the medulla oblongata (Figures 3A,B). Other T2 hyperintense lesions were found in the pons, in the left temporal and right frontal periventricular white matter, and in the cervical spinal cord at the level of C4 (Figures 3C,D).