Discussion
The pathogenic mechanisms behind TTS and TGA remain unsolved, but a catecholamine surge may be part of the underlying pathophysiology.[1][15] Based on several pathophysiologic findings, it has been suggested that TGA might be a “cerebral Takotsubo”.[16]
The presented patient suffered from two comorbidities which are known to be associated with TTS as well as TGA, migraine and hypothyroidism. Migraine has been identified as a risk factor for TTS as well as TGA.[1][15][17] Hypothyroidism is more frequent in patients with TTS as well as TGA than in the general population.[17][18][19] The pathomechanism of hypothyroidism as well as migraine in these disorders, however, is unclear.
The coincidence of TGA and TTS associated with a long-lasting stressor has, to our knowledge, only described in one case.[12] (Table) Of note, similar to our patient, the reported female suffered from hypothyroidism.
The comedication of our patient may possibly have contributed to the development of TTS. TTS has been reported after ingestion of a weight management supplement containing caffeine and amphetamine-like stimulants.[20] In a further case, TTS occurred after a combined drug intoxication containing acetaminophen.[21]
We conclude that TTS and TGA can occur simultaneously even after long-standing stressors. Probably, hypothyroidism and migraine make the patient more susceptible to TTS and TGA.