Increased right amygdala activity during the hyper-acute phase of takotsubo syndrome

Takotsubo syndrome (TTS) is a heart failure syndrome featured by transient left ventricular dysfunction due to emotional or physical trigger. Recent studies showed that patients that will develop TTS have increased activity of brain emotional areas as amygdala. A 66-year-old woman affected by ovarian carcinoma with multiorgan metastasis has been admitted to the Neurology Department due to recurrent episodes of motor aphasia followed by prolonged decreased level of consciousness. She underwent brain magnetic resonance and electroencephalogram (EEG) that were normal. Laboratory test and cardiological evaluation were normal. Cerebrospinal fluid cytology was positive for cancer cells. Two days later, the patient underwent brain 18-fluorodeoxyglucose positron emission tomography/computed tomography (CT) that highlighted relative hypermetabolism in the right amygdala (A) and areas of relative hypometabolism bilaterally in the fronto-parietal and parieto-occipital cortex (B). Few hours after this exam, the patient became suddenly comatose (Glasgow Coma Scale = 3), laboratory tests were normal except for increased levels of high-sensitive troponin I (1254.3 ng/L). The ECG showed sinus rhythm and ST elevation in V2–V3, while echocardiogram revealed reduced left ventricular ejection fraction (35%) with apical ballooning. Coronary angiogram was normal. In the meantime, brain CT scan and EEG were repeated and were normal. During hospitalization, cardiological parameters turned normal within 10 days. Therefore, TTS diagnosis associated to leptomeningeal carcinomatosis was made. Unfortunately, after 28 days, the patient died due to acquired pneumonia. We report during the hyperacute phase of TTS an increased activity of the right amygdala, a brain area that is associated with negative emotions. No data were generated or analysed for or in support of this paper.