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BACKGROUND: Takotsubo syndrome (TS) is a reversible cause of heart failure; however, a minority of patients can develop serious complications, including cardiac rupture (CR). OBJECTIVES: Analyze case reports of CR related to TS, detailing patient characteristics to uncover risk factors and prognosis for this severe complication. METHODS: We conducted a systematic search of MEDLINE and Embase databases to identify case reports of patients with TS complicated by CR, from inception to October 2023. RESULTS: We included 44 subjects (40 females; 4 males) with a median age of 75 (IQR 71-82) years, of White/Caucasian (61%) or East Asian/Japanese (39%) ethnicity. An emotional trigger was present in 15 (34%) subjects and an apical ballooning pattern was observed in all cases (100%). ST-segment elevation was reported in 39 (93%) of 42 cases, with the anterior myocardial segments (37 [88%]) being the most compromised, followed by lateral (26 [62%]) and inferior (14 [33%]) segments. The median time to cardiac rupture was 48 (5-120) hours since admission, with the left ventricular free wall (25 [57%]) being the most frequent site of perforation. Surgery was attempted in 16 (36%) cases, and 28 (64%) patients did not survive. CONCLUSIONS: CR related to TS is a rare complication associated with high mortality and affecting elderly females, specially from White/Caucasian or East Asian/Japanese descent, presenting with anterior or lateral ST-segment elevation, and an apical ballooning pattern. Although data is limited and additional prospective studies are needed, the awareness of this life-threatening complication is crucial to early identify high-risk patients. CONDENSED ABSTRACT: Cardiac rupture is a rare complication of Takotsubo syndrome. We conducted a systematic review of cases complicated by cardiac rupture, and we identified 44 subjects (40 females and 4 males) with a median age of 75 (IQR 71-82) years, of White/Caucasian (61%) or East Asian/Japanese (39%) ethnicity, all with an apical ballooning pattern (100%). The median time to cardiac rupture was 48 (5-120) hours since admission, with the left ventricular free wall (25 [57%]) being the most frequent site of perforation. Surgery treatment was attempted in 16 (36%) cases, and 28 (64%) patients did not survive.

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Introducción: El término MINOCA (Myocardial Infarction with Non-Obstructive Coronary Arteries) ha cobrado relevancia como diagnóstico de trabajo en el contexto de pacientes con sospecha de isquemia miocárdica y estudio coronario sin lesiones obstructivas. Objetivos: Describir las distintas etiologías y variables clínicas de pacientes con MINOCA hospitalizados en la unidad coronaria de nuestro centro (Hospital de la P Universalidad de Chile) Métodos: Estudio observacional retrospectivo en el que se realizó un análisis descriptivo de las variables estudiadas. Además, se analizó el uso de los métodos de imágenes complementarios y otras variables pronósticas. El seguimiento se realizó dentro del primer año posterior al evento. Resultados: El diagnóstico etiológico más frecuente de los pacientes con MINOCA fue el de miocardiopatía por estrés (MCE). Se incluyeron 55 pacientes, 55% de ellos mujeres. La edad promedio fue 57 años y la frecuencia de factores de riesgo cardiovascular clásicos (FRCV) fue baja. En los pacientes con MCE se observó menores niveles de troponina ultrasensible; mayores niveles de NT-proBNP y mayor mortalidad en comparación a otras etiologías. Conclusiones: El perfil de pacientes con MINOCA hospitalizados en nuestro centro correspondió predominantemente a mujeres postmenopáusicas con baja frecuencia de FRCV. La mortalidad de los pacientes con MINOCA se concentró en el grupo con MCE.

Background: MINOCA (acronym for "Myocardial Infarction with Non-Obstructive Coronary Arteries") is relevant as a working guide in the diagnosis of patients with suspicion of ischemia and absence of obstructive coronary artery disease. Aim: to describe the different causes and clinical variables in patients with MINOCA admitted to a coronary care unit of a University hospital in Santiago, Chile. Methods: this is an observational retrospective analysis of relevant clinical variables in 55 patients finally diagnosed as having MINOCA. Use of image based studies and characteristics related to prognosis were also analyzed. Follow up extended for one year after the event. Results: 55 patients were included, 55% of them women. Mean age was 57 years; presence of traditional risk factors for myocardial infarction was low. The most common eventual etiologic diagnosis was Stress Cardiomyopathy (SCM) in which lower levels of ultrasensitive troponin and higher levels of NT-proBNP were observed. Mortality in SCM was higher than that observed in other etiologies. Conclusion: MINOCA was more frequent in post menopausal women. Mortality was greater in patients with SMC.

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BACKGROUND: A list of drugs that can induce takotsubo cardiomyopathy (TCM) was published in 2011 and 2016. The aim of the present review was to update this list. METHODS: Similar to the 2011 and 2016 reviews, from April 2015 to May 2022 case reports of druginduced TCM were identified by a comprehensive search in Medline/PubMed database. The search terms were: takotsubo cardiomyopathy, tako-tsubo cardiomyopathy, stress cardiomyopathy, transientleft- ventricular ballooning syndrome, apical ballooning syndrome, ampulla cardiomyopathy OR broken heart syndrome; together with "iatrogenic", "induced by" OR "drug-induced". Registers published in English or Spanish, in humans, and with full texts were retrieved. Articles that recognized any drug associated with the development of TCM were selected. RESULTS: Overall, 184 manuscripts were identified by the search. A total of 39 articles were included after an exhaustive revision. Eighteen drugs as possible triggers of TCM were identified in the current update. Of them, 3 (16.7%) have been previously identified, and 15 (83.3%) are different from the previous reports. Thus, the list of drugs as possible triggers of TCM updated in 2022 includes 72 drugs. CONCLUSION: There are new case reports that link drugs with the development of TCM. The current list is principally made up of drugs that generate sympathetic overstimulation. However, some of the listed drugs do not have a clear link with sympathetic activation.

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Endothelial Growth Factor Receptor (EGFR) mutations are frequently found among NSCLC patients. Second-generation Tyrosine Kinase Inhibitor (TKI) Afatinib is frequently used in this population of patients achieving better results than cytotoxic chemotherapy in terms of survival and progression. Afatinib-related cardiotoxicity has been rarely reported. Here we comment on a clinical case of a Takotsubo Cardiomyopathy Afatinib-induced in an NSCLC patient.

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Resumen El síndrome de takotsubo, también conocido como miocardiopatía de estrés, representa un difícil reto diagnóstico, pues en muchos casos su presentación es superponible al infarto de miocardio por ruptura de placa; el diagnóstico definitivo se basa en la ausencia de lesiones culpables en la coronariografía. La fisiopatología de la enfermedad no está por completo establecida, y tiene un pronóstico generalmente benigno. Sin embargo, existe un porcentaje no despreciable de pacientes que sufren complicaciones graves, entre las que destacan las arritmias malignas tipo taquicardia ventricular polimórfica por prolongación del intervalo QT. A pesar de que el síndrome de takotsubo afecta principalmente a las mujeres, quienes por otra parte también suelen tener intervalos QT más prolongados en condiciones basales, la muerte súbita de origen arrítmico aparece con mayor frecuencia en los hombres que sufren esta enfermedad. Se presentan dos casos de ensanchamiento extremo del intervalo QT corregido en pacientes con takotsubo que tuvieron desenlaces diferentes. El propósito de este trabajo es destacar y revisar las diferencias electrocardiográficas y pronósticas relacionadas con el sexo de los sujetos que desarrollan esta controvertida enfermedad.

Abstract Takotsubo syndrome, also known as stress cardiomyopathy, is a difficult diagnostic challenge as, in many cases, its presentation can overlap with that of myocardial infarction due to plaque rupture. The definitive diagnosis is based on the lack of culprit lesions on coronariography. The pathophysiology of the disease has not been completely ascertained, and it has a generally benign prognosis. However, a not inconsiderable percentage of patients experience serious complications, notably malignant arrhythmias like polymorphic ventricular tachycardia due to a prolonged QT interval. Despite takotsubo syndrome affecting mainly women who, furthermore, generally have longer basal QT intervals, sudden death due to arrhythmias is more common in men with this disease. Two cases are presented of extremely prolonged corrected QT intervals in patients with takotsubo, with different outcomes. The purpose of this paper is to highlight and review the electrocardiographic and prognostic differences related to the gender of the individuals who develop this controversial disease.

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El Síndrome de Takotsubo es una disfunción ventricular aguda reversible en ausencia de obstrucción coronaria. Una mujer de 85 años de edad con antecedentes de reemplazo valvular aórtico transcatéter, ingresó por dos semanas de dolor severo por una cadera desplazada por osteosíntesis fallida. Mientras se programaba para cirugía, se documentó hiponatremia severa secundaria a secreción inapropiada de hormona antidiurética. Súbitamente desarrolló edema agudo pulmonar. El ecocardiograma confirmó una válvula protésica funcional y aquinesia medial y apical de las paredes del ventrículo izquierdo. Recibió tratamiento con ventilación mecánica no invasiva, restricción de líquidos y diuréticos. La hiponatremia y la cardiomiopatía resolvieron.Takotsubo syndrome is a form of acute reversible left ventricular dysfunction in the absence of coronary obstruction. An 85-year-old lady with a medical history of transcatheter aortic valve replacement was readmitted complaining of 2 weeks of severe pain by a displaced hip and failed osteosynthesis. While she was scheduled for hip surgery, severe hyponatremia secondary to inappropriate antidiuretic hormone secretion was documented, and sudden-onset pulmonary edema ensued. Echocardiography confirmed normally functioning aortic prosthetic valve and classical features of Takotsubo. She was treated with non-invasive mechanical ventilation, water restriction, and diuretics. Hyponatremia and the cardiomyopathy resolved and the patient recovered completely.

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Takotsubo syndrome - also known as broken-heart syndrome, Takotsubo cardiomyopathy, and stress-induced cardiomyopathy - is a recently discovered acute cardiac disease first described in Japan in 1991. This review aims to update understanding on the epidemiology, pathophysiology, clinical presentation, diagnosis, and treatment of Takotsubo syndrome, highlighting aspects of interest to cardiologists and general practitioners.

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BACKGROUND: Takotsubo syndrome (TTS), also known as stress cardiomyopathy, apical ballooning syndrome and broken heart syndrome, is characterized by acute-onset chest pain, electrocardiographic (ECG) abnormalities and reversible left ventricular (LV) disfunction in the absence of a culprit obstructive lesion in the coronary arteries; therefore, myocardial infarction is the most important differential diagnosis. Usually induced by emotional/physical stress, its treatment consists in hemodynamic support until complete and spontaneous recovery occurs, which is generally achieved within a few days to weeks. Cervical malignancies are an important public health issue in low/middle-income countries and, in the setting of locally advanced disease, concurrent chemoradiation followed by brachytherapy is considered the standard treatment, harboring curative potential. CASE REPORT: We report a case of a 38-year-old woman who underwent concurrent chemoradiotherapy and developed cardiopulmonary arrest in ventricular fibrillation during a brachytherapy session. Complementary tests disclosed altered ECG and cardiac biomarkers, no evidence of coronary artery obstruction, as well as LV disfunction consistent with TTS on echocardiogram and cardiac MRI. After few days of supportive therapy, complete recovery of heart function was observed. CONCLUSIONS: Especially for cancer patients, who usually experience intense emotional/physical stress intrinsically associated with their diagnosis and aggressive treatments, considering TTS as a differential diagnosis is warranted. Intracavitary brachytherapy procedure may represent a trigger for TTS.

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Resumen El síndrome de takotsubo o miocardiopatía por estrés es una alteración de la funcionalidad miocárdica, que se asocia con frecuencia a situaciones de estrés físico o emocional. Corresponde entre el 1 y el 2% de todos los ingresos a urgencias por síndrome coronario agudo y tiene una prevalencia y tasa de mortalidad de 4,1% y 2% a 8%, respectivamente. Hasta el 10% de los pacientes presenta algún tipo de complicación. En Colombia los datos epidemiológicos son limitados. En la actualidad se desconoce con exactitud la fisiopatología subyacente y no hay consenso acerca del tratamiento del síndrome y las complicaciones asociadas; por consiguiente, estos interrogantes son posibles temas de investigación. Se expone un caso clínico de características inusuales, que cursó con alteraciones electrocardiográficas, cinéticas y de conducción miocárdica infrecuentes, además de evolución clínica inesperada, que culminó en paro cardiorrespiratorio secundario a taquicardia ventricular polimórfica por persistencia del intervalo QT prolongado. Con base en la experiencia clínica y en la evidencia científica disponible se recomienda monitorizar estrechamente a los pacientes con alteración adquirida de la repolarización miocárdica hasta que esta se normalice y considerar la implantación de un dispositivo cardiaco tipo cardiodesfibrilador en casos de alto riesgo.

Abstract Takotsubo syndrome or stress cardiomyopathy is a myocardial functional disorder, which is often associated with situations of physical or emotional stress. It accounts for between 1% and 2% of all those admitted to the Emergency Department due to acute coronary syndrome, and has a prevalence and mortality rate of 4.1% and 2% to 8%, respectively. Up to 10% of the patients have some type of complication. Epidemiological data are scarce in Colombia. The underlying pathophysiology is still not exactly known, and there is no consensus on the treatment of the syndrome and the associated complications. Therefore, these questions are possible research topics. A clinical case of unusual characteristics is presented, which included rare electrocardiographic, kinetic, and myocardial conduction characteristics. It also had an unexpected clinical outcome, which culminated in cardiorespiratory arrest secondary to a polymorphic ventricular tachycardia due to persistence of the prolonged QT interval. Based on clinical experience and on the available scientific evidence, it is recommended to closely monitor patients with an acquired change in myocardial repolarisation until it returns to normal, and to consider an implantable cardioverter defibrillator in cases of high risk.

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We report three cases of Takotsubo syndrome (TS) with atypical myocardial involvement. All three cases were triggered by physical or mental stress, resulting in transient myocardial compromise. However, the clinical presentation, localization and extent of myocardial damage varied in each case, ranging from low-risk acute chest pain to cardiogenic shock with low ejection fraction and dynamic obstruction of the left ventricular outflow tract. These cases outline the range of possible presentations of this rare entity and illustrate atypical forms of TS.

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La cardiomiopatía inducida por estrés o Síndrome de Takotsubo se caracteriza por una disfunción aguda del ventrículo izquierdo caracterizado por acinesia o discinesia apical con hipercinesia basal a menudo reversible, en ausencia de obstrucción coronaria en la angiografía. La presentación clínica se asemeja al del Infarto Agudo de Miocardio; con un inicio súbito caracterizado por dolor precordial de tipo isquémico, disnea, palpitaciones, cambios electrocardiográficos, elevación de biomarcadores de necrosis miocárdica y en casos más graves y raros shock cardiogénico; el estrés emocional y físico severo suelen ser desencadenantes. Con el presente caso clínico, revisamos las características clínicas, diagnósticas y terapéuticas de ésta entidad poco frecuente que representa cerca del 1% de todos los pacientes con sospecha de síndrome coronario agudo.

Cardiomyopathy induced by stress or Takotsubo Syndrome is characterized by an acute dysfunction of the left ventricle characterized by apical akinesia or dyskinesia with often reversible basal hyperkinesia, in the absence of coronary occlusion on angiography. The clinical presentation resembles the Acute Myocardial Infarction, with a sudden onset characterized by a chest pain angina type, dyspnea, palpitations, electrocardiographic changes, elevation of cardiac biomarkers and cardiogenic shock in more serious and rare cases; the severe emotional and physical stress tend to be triggers. With this clinical case, we reviewed the clinical, diagnostic and therapeutic features of this rare entity which represents about 1% of all patients with suspected acute coronary syndrome.

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Resumen Antecedentes: El síndrome de takotsubo secundario a traumatismo raquimedular cervical es infrecuente y no se describen series de casos en la literatura. Pacientes y método: Se describe el caso clínico de una mujer de 82 años que ingresó en la Unidad de Cuidados Intensivos tras traumatismo raquimedular cervical y como consecuencia desarrolló miocardiopatía de takotsubo. Resultado: Desarrollo de una miocardiopatía de takotsubo tras un traumatismo raquimedular cervical. Conclusiones: En la actualidad el diagnóstico de miocardiopatía de takotsubo en Cuidados Intensivos está en aumento, en parte por el uso de la ecocardiografía trastorácica por parte de los Intensivistas; con ello se descartan otras causas posibles de la misma y no sólo la cardiológica o la descarga catecolaminérgica secundaria a una situación de estrés.

Abstract Background: Takotsubo syndrome secondary to spinal cord injury is rare, and there are no case series described in the literature. Patients and method: A clinical case is presented of an 82 year-old woman admitted to the Intensive Care Unit after a spinal cord injury, and as a results developed Takotsubo cardiomyopathy. Results: A Takotsubo cardiomyopathy developed after a spinal cord injury. Conclusions: The diagnosis of Takotsubo cardiomyopathy is currently increasing in Intensive Care Units. This is partly due to use of transthoracic echocardiography by intensive care specialists. Using this technique they can rule out other possible causes of this condition, and not just the cardiological ones, or the catecholamine release following a stressful event.

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Resumen: Las manifestaciones cardiacas en el paciente neurocrítico, en especial pacientes con hemorragia subaracnoidea y evento vascular cerebral, ha sido tema de investigación en los últimos años. La manifestación va desde cambios electrocardiográficos, elevación de biomarcadores y colapso hemodinámico hasta la muerte secundaria al descontrol del equilibrio de electrólitos y de catecolaminas circulantes. El propósito de este artículo es identificar a este tipo de pacientes y realizar un diagnóstico diferencial con el síndrome coronario agudo con elevación del ST que se manifiesta en pacientes neurocríticos.

Abstract: Cardiac manifestations in patients with brain injury, especially patients with subarachnoid hemorrhage and cerebral vascular event have been the subject of research in recent years. The presentation goes from electrocardiographic changes, elevated biomarkers, hemodynamic collapse to death secondary to lose control of electrolyte balance and circulating catecholamines. The purpose of reporting this case is to present this important differential diagnosis of acute coronary syndrome with ST elevation that occurs in neurocritical patients.

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La miocardiopatía Takotsubo, o miocardiopatía por estrés, se define como una disfunción del segmento apical del ventrículo izquierdo, aguda, transitoria y reversible. Normalmente se relaciona con algún tipo de agente estresante, ya sea físico o emocional, pudiendo confundirse este cuadro con un síndrome coronario agudo. Se considera una patología rara, pero que es importante incluir en el diagnóstico diferencial de los trastornos cardiacos, sospechándolo previamente por la sintomatología. Está caracterizado por alteraciones en el electrocardiograma, como elevación del segmento ST en derivaciones precordiales e inversión de la onda T, elevación de las enzimas de necrosis miocárdica o patrones alterados en la ecocardiografía, como la disfunción ventricular apical con hiperquinesia de zonas basales. En cuanto a la fisiopatología, parece que la estimulación simpática juega un papel importante, en el que la disfunción ventricular se desencadena por algún tipo de estrés físico o emocional. Éste provoca una descarga de catecolaminas con un efecto cardiotóxico debido, en su mayor parte, al efecto del adenosín monofosfato cíclico. El tratamiento consiste en las medidas soporte de una miocardiopatía, evitando los fármacos teratogénicos o perjudiciales durante el periodo de lactancia. La evolución es favorable en la mayoría de los casos y el cuadro remite por completo, por lo que el pronóstico en líneas generales se considera bueno. En este trabajo se expone el caso de un parto instrumentado, en el que se manifiesta un cuadro compatible con una miocardiopatía Takotsubo, posiblemente relacionado con un procedimiento invasivo como factor desencadenante.

Takotsubo cardiomyopathy or stress cardiomyopathy is defined as an acute, transient, and reversible dysfunction of the apical segment of the left ventricle. It is usually associated with some sort of stressor, whether physical or emotional, and could be confused with an acute coronary syndrome. It is considered a rare disease, so it is important to include it in the differential diagnosis, previously suspecting the symptoms. It is characterized by alterations in the electrocardiogram such as ST segment elevation and inversion of the T wave in precordial leads, elevation of myocardial necrosis enzymes, or altered patterns on echocardiography such as apical ventricular dysfunction with hyperkinesia of basal areas. Regarding the pathophysiology, it seems that sympathetic stimulation plays an important role, in which ventricular dysfunction is triggered by some kind of physical or emotional stress. This causes a release of catecholamines with cardiotoxic effects due, mostly, to the effect of cyclic AMP. Treatment involves cardiomyopathy supportive care, avoiding teratogenic or harmful drugs during lactation. The evolution is favorable in most cases and the clinical picture abates completely, so the prognosis is generally considered good. In this paper, we expose a case of an instrumental labor in which a clinical picture compatible with Takotsubo cardiomyopathy is presented, triggered by an invasive procedure.

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Stress cardiomyopathy (SC) is characterized by transient left ventricular (LV) wall motion abnormalities typically involving the apex with preserved basal contractility, chest discomfort, ST-T ischemic changes and elevated cardiac markers with normal or non-flow limiting coronary artery lesions. It represents an important differential diagnosis of Acute Coronary Syndromes caused by atherosclerotic vessel occlusion; most commonly, Tako-tsubo occurs in postmenopausal women after physical or emotional stress. While the exact mechanism of SC remains controversial, various hypotheses have been suggested concerning the vascular, central nervous and endocrine system participation where catecholamines, particularly epinephrine, seem to play a major role. Hormonal, genetic and psychiatric conditions may also define the risk of susceptibility in some groups affected by SC. Long-term survival data are limited with mortality occurring predominantly in the first year after diagnosis usually related to non-cardiac illnesses. Echocardiography promises to become a useful tool to correctly identify SC patients at high risk for complications.

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Takotsubo cardiomyopathy (TC) is a disease that can be misinterpreted as a more serious acute coronary syndrome. Its clinical characteristics resemble those of a myocardial infarct, while its imaging characteristics are critical on correctly characterizing and diagnosing the disease. From angiography, where coronary anatomy is evaluated, to cardiac magnetic resonance (CMR), where morphology and tissue characterization is assessed, the array of imaging options is quite extent. In particular, CMR has achieved great improvements (stronger magnetic fields, better coils, etc.) in the last decade which in turn has made this imaging technology more attractive in the evaluation and diagnosis of TC. With its superior soft tissue resolution and dynamic imaging capabilities, CMR is currently, perhaps, the most useful imaging technique in TC as apical ballooning or medio-basal wall motion abnormalities (WMA), presence of wall edema and late gadolinium enhancement (LGE) characteristics are critical in the diagnosis and characterization of this pathology. In this review, CMRs role in TC will be evaluated in light of the current available evidence in medical literature, while also revising the clinical and physiopathologic characteristics of TC.

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AIM: To review the initial presentation and demonstrate the importance of Takotsubo cardiomyopathy. METHODS: A PubMed search using the terms "Takotsubo cardiomyopathy (TC)" and "apical ballooning syndrome" yielded 211 publications. Only those that were relevant were fully reviewed. The gender, age, precipitating stressor, main complaint at presentation, electrocardiogram (ECG) at admission and serum cardiac markers of patients diagnosed with TC, were extracted as available. The data were organized in tables and graphics, and the incidence of the disorder was calculated and analyzed. RESULTS: A total of 250 clinical cases were examined. The predominant gender that was affected was female, with a prevalence of 87.5%. The mean age of presentation was 64 ± 14 years. The cases were divided by age into 10-year intervals. The age interval of 60-69 years showed the highest frequency of TC, accounting for 79 cases. The most common precipitating stressor was physical (50% of cases). Chest pain was the primary complaint at presentation (58.8% of cases) followed by dyspnea (30% of cases). The ST segment changes category was the most common (60%), followed by T wave changes (39.6%). Of the 60% of cases with ST segment changes, 12% had concomitant T wave changes. This means that for 27.6% of the cases, the primary abnormality in the ECG was T wave changes; 87.6% of cases with TC had a change in the ST segment, in the T wave or in both. The percentage of ECGs presenting with changes in the anterior wall was 54.4% (35.6% of ST segment elevation + 1.6% of ST segment depression + 17.2% of T wave inversion). The percentage of patients presenting with changes in the lateral segment of the heart was 46.8%, while the percentage of patients with changes in the inferior heart was 21.6% and the percentage of patients with changes in the apical region was only 16%. The prevalence of elevated creatinine kinase and/or troponin on initial presentation was 89.3%. CONCLUSION: It is essential that every physician consider Takotsubo cardiomyopathy as a possible differential diagnosis when a patient is classified with acute coronary syndrome. To do so, it is necessary to know the clinical presentation of this syndrome in its early stages.

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La muerte súbita de una persona durante un asalto o una agresión física resulta de gran importancia e interér en el medio forense debido a las interrogantes que genera la determinación de la causa y manera de muerte, principalmente en aquellas cuyos traumatismo por si solos no justifiquen la muerte. En estos casos especiales trasciende la Miocardiopatía por Estrés como una hipótesis que se debe analizar. En la actualidad, ésta patología se encuentra ampliamente descrita tanto a nivel de la medicina curativa como en la Patología Forense; y en ésta última su demostración objetiva es esencial, con el fin de cumplir los criterios de casualidad. En este artículo se expone la valoración de un caso valorado en la Sección de Patología Forense del Departamento de Medicina Legal de Costa Rica...

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