Objective:

N/A

Background:

 Posterior reversible encephalopathy syndrome (PRES) and Takotsubo Cardiomyopathy (TC) are constructs with reversible clinical symptoms and radiographic features with proposed shared molecular signaling pathways are a rare entity to occur concomitantly. PRES-Takotsubo dual diagnosis is attributed to a single catecholamine surge, leading to endothelial dysfunction in cerebral arteries and coronary arteries and myocardial stunning. This theory, however, is seemingly oversimplified and does not address the intricacies of cytotoxic/inflammatory communication between systems. There are no case that describes if PRES precedes TC or vice a versa and how it would improve patient outcome or avoid further life-threatening conditions such as cardiogenic shock which occurred in our patient. 

Design/Methods:

N/A

Results:

72-year-old female with extensive cardiac history with mechanical mitral valve presented with left gaze preference, facial twitching followed by unresponsiveness raising suspicion of seizure versus stroke. CT of head showed hypodensities in bilateral occipital lobes, followed with MRI that showed bilateral white matter hyperintensities in the occipital and frontal lobes, area of restricted diffusion in the right occipital lobe favoring atypical PRES. EKG sowed no ST segment changes and troponin 0.086. Treatment with levetiracetam improved her encephalopathy, but hospitalization was complicated by cardiogenic shock requiring ionotropic support. Echocardiogram findings were consistent with TC. No clear etiology of PRES identified. Repeat TTE in few days showed EF back at 60%. 

Conclusions:

Considering patient initial presentation of seizure with no ST segment changes on EKG and mild troponin elevation supports hypothesis of PRES further causing TC with no clear inciting factor for PRES. The case concludes that patient could have idiopathic PRES with extensive cardiac history. Cardiac biomarkers and EKG should be obtained. If any cardiac markers abnormal thorough cardiologic work up should be performed however conversely patient with TC if patient has any neurologic clinical symptoms further neurological work up is warranted