Takotsubo syndrome in a stroke patient with carotid artery stenosis

Takotsubo syndrome (TTS) is a transient transient left ventricular dysfunction, predominantly affecting elderly women and often preceded by emotional or physical stress. TTS may be the cause as well as the consequence of stroke. We report a 82-years old female with a history of long-standing untreated arterial hypertension who was hospitalized because of a left-sided tongue paralysis and dysarthria. Cerebral magnetic resonance imaging showed ischemic lesions in the territory of the right middle cerebral artery affecting the capsula interna and gyrus praecentralis. The carotid and cerebral arteries showed extensive atherosclerotic wall irregularities, a high-grade stenosis of the M1-segment of the right middle cerebral artery and a 60% stenosis of the internal carotid artery at its origin. Elevated creatine-kinase and Pro-brain-natriuretic peptide levels and development of new ischemic signs in the electrocardiogram suggested myocardial infarction, although the patient did not complain about cardiac symptoms. Echocardiography showed apical ballooning which resolved during the following days. The patient refused coronary angiography why the diagnosis of TTS was not completely established. However, normalization of echocardiogram and ECG were indicative for TTS. TTS has to be considered in stroke patients, irrespective of their etiology. Since patients often do not report typical symptoms or may even be asymptomatic, TTS can be overlooked. If the ECG in stroke patients shows signs of myocardial ischemia, troponin and BNP levels should be measured whose ratio may even help to differentiate between TTS and myocardial infarction. Echocardiography, coronary angiography and follow-up investigations are needed to confirm the diagnosis of TTS.