Neurocritical Care

, 11:395

One Thing Leads to Another: GBS Complicated by PRES and Takotsubo Cardiomyopathy

  • Jennifer E. Fugate
  • Eelco F. Wijdicks
  • Gautam Kumar
  • Alejandro A. Rabinstein
Practical Pearl



To describe a patient with Guillane–Barré syndrome (GBS), posterior reversible encephalopathy syndrome (PRES) and takotsubo cardiomyopathy, and in doing so, to postulate a new mechanism for hypotension in the setting of dysautonomia in GBS.


Case report.


We report an 82-year-old woman who presented with bilateral lower extremity weakness and back pain following an upper respiratory viral illness. Within 4 days she became markedly hypertensive and developed status epilepticus. Brain MRI revealed patchy bilateral occipital lesions with T2 signal hyperintensity consistent with PRES. Her clinical exam, CSF, and electrophysiologic findings were consistent with GBS. She became relatively hypotensive and transthoracic echocardiogram showed severe apical akinesis. The patient clinically improved, and echocardiogram and MRI abnormalities resolved within 2 weeks.


The autonomic effects of GBS may cause a variety of reversible clinical syndromes associated with sympathetic dysfunction including PRES and takotsubo cardiomyopathy; both of which are self-limited. Relative hypotension in GBS may be caused in part by neurogenic stunned myocardium.


Posterior reversible encephalopathy syndrome Reversible posterior leukoencephalopathy syndrome Apical ballooning syndrome Takotsubo cardiomyopathy Guillain–Barré syndrome Autonomic disorders Demyelinating disease 


  1. 1.
    Zochodne DW. Autonomic involvement in Guillain–Barre syndrome: a review. Muscle Nerve. 1994;17:1145–55.CrossRefPubMedGoogle Scholar
  2. 2.
    Flachenecker P. Autonomic dysfunction in Guillain–Barre syndrome and multiple sclerosis. J Neurol. 2007;254(Suppl 2):II96–101.CrossRefPubMedGoogle Scholar
  3. 3.
    Hinchey J, Chaves C, Appignani B, et al. A reversible posterior leukoencephalopathy syndrome. N Engl J Med. 1996;334:494–500.CrossRefPubMedGoogle Scholar
  4. 4.
    Schwartz RB, Jones KM, Kalina P, et al. Hypertensive encephalopathy: findings on CT, MR imaging, and SPECT imaging in 14 cases. AJR Am J Roentgenol. 1992;159:379–83.PubMedGoogle Scholar
  5. 5.
    Bybee KA, Kara T, Prasad A, et al. Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction. Ann Intern Med. 2004;141:858–65.PubMedGoogle Scholar
  6. 6.
    Lyon AR, Rees PS, Prasad S, Poole-Wilson PA, Harding SE. Stress (Takotsubo) cardiomyopathy—a novel pathophysiological hypothesis to explain catecholamine-induced acute myocardial stunning. Nat Clin Pract Cardiovasc Med. 2008;5:22–9.CrossRefPubMedGoogle Scholar
  7. 7.
    Wittstein IS, Thiemann DR, Lima JA, et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med. 2005;352:539–48.CrossRefPubMedGoogle Scholar
  8. 8.
    Akashi YJ, Musha H, Nakazawa K, Miyake F. Plasma brain natriuretic peptide in takotsubo cardiomyopathy. QJM. 2004;97:599–607.CrossRefPubMedGoogle Scholar
  9. 9.
    Banuelos PA, Temes R, Lee VH. Neurogenic stunned myocardium associated with reversible posterior leukoencephalopathy syndrome. Neurocrit Care. 2008;9:108–11.CrossRefPubMedGoogle Scholar
  10. 10.
    Palazzuoli A, Lenzi C, Iovine F, Carrera A, Nuti R. A case of acute heart failure associated with Guillain–Barre syndrome. Neurol Sci. 2006;26:447–50.CrossRefPubMedGoogle Scholar
  11. 11.
    Elahi A, Kelkar P, St Louis EK. Posterior reversible encephalopathy syndrome as the initial manifestation of Guillain–Barre Syndrome. Neurocrit Care. 2004;1:465–8.CrossRefPubMedGoogle Scholar
  12. 12.
    Van Diest D, Van Goethem JW, Vercruyssen A, Jadoul C, Cras P. Posterior reversible encephalopathy and Guillain–Barre syndrome in a single patient: coincidence or causative relation? Clin Neurol Neurosurg. 2007;109:58–62.CrossRefPubMedGoogle Scholar
  13. 13.
    Koichihara R, Hamano S, Yamashita S, Tanaka M. Posterior reversible encephalopathy syndrome associated with IVIG in a patient with Guillain–Barre syndrome. Pediatr Neurol. 2008;39:123–5.CrossRefPubMedGoogle Scholar
  14. 14.
    Bartynski WS. Posterior reversible encephalopathy syndrome, part 2: controversies surrounding pathophysiology of vasogenic edema. AJNR Am J Neuroradiol. 2008;29:1043–9.CrossRefPubMedGoogle Scholar

Copyright information

© Humana Press Inc. 2009

Authors and Affiliations

  • Jennifer E. Fugate
    • 1
  • Eelco F. Wijdicks
    • 1
  • Gautam Kumar
    • 2
  • Alejandro A. Rabinstein
    • 1
  1. 1.Department of NeurologyMayo ClinicRochesterUSA
  2. 2.Department of Cardiovascular DiseasesMayo ClinicRochesterUSA

Personalised recommendations