Takotsubo cardiomyopathy (TCM) is a non-ischemic transient myocardial dysfunction associated with several acute neurologic diseases. Rarely, it has been associated with PRES, with ten cases reported in the literature to date. We present a case of PRES requiring sedation and intubation, with subsequent acute heart failure from Takotsubo cardiomyopathy and full recovery within one week of onset. 

Case
A 49-year-old woman with hypertension presented after a generalized seizure. On arrival to MGH, she was hemodynamically stable. Due to agitation, she was intubated and sedated to obtain diagnostic imaging. MRI (Fig 1-3) showed subcortical and cortical T2/FLAIR hyperintensity with some associated diffusion restriction (Figure 4) in the bilateral frontal, parietal and occipital lobes and in the right cerebellar hemisphere, suggestive of PRES.

She became hypotensive requiring vasopressors and developed pulmonary edema. An echocardiogram showed an ejection fraction of 28% and segmental LV wall motion abnormalities (Figure 5) with preserved basal wall segments, consistent with TCM. ECG showed T wave inversions in the inferolateral leads (Figure 6). After two days of diuresis with a furosemide infusion and hemodynamic support, her neurologic and pulmonary status improved. She was extubated on hospital day 5. By hospital day 7, she had a normal mental status exam and no neurologic deficits. Repeat echocardiogram showed recovery of ejection fraction to 53%, and ECG abnormalities resolved. 

Discussion
The pathophysiology of PRES and TCM is speculative, and similar mechanisms have been proposed for both; studies have shown elevated circulating catecholamine levels, which may induce microvascular dysfunction.

Conclusions
Although acute illness is suggested to trigger both, our case suggests that isolated PRES itself may be an inciting factor for developing TCM. Further study such as routine echocardiogram and serum catecholamine levels on patients presenting with PRES may help in understanding incidence and pathophysiology of these rare conditions.