takotsubo cardiomyopathy , also called ' stress - induced cardiomyopathy ' , has clinical features that resemble an acute coronary syndrome , such as chest pain , st - segment changes observed on electrocardiography , mild elevation of serum cardiac enzymes , and transient left ventricular ( lv ) dysfunction with marked apical dyskinesis and ballooning ; however , angiographic features of significant coronary artery disease are absent.1 - 5 ) the general prognosis is considered to be favorable , although some investigators have reported cases with various complications , including death.4)6 ) lv thrombus is a known complication of stress - induced cardiomyopathy.7 - 9 ) however , the clinical significance and therapy of lv thrombus in stress - induced cardiomyopathy remain unclear . authors experienced a 76-year - old woman who had embolic cerebral infarction following lv thrombus with stress - induced cardiomyopathy . a 76-year - old woman , with a past medical history of hypertension and diabetes mellitus , visited the emergency department for worsening nausea and abdominal discomfort . on admission , her mental status was alert , the blood pressure was 90/60 mmhg , respiratory rate was 22 per minute , pulse rate was 110 per minute , and temperature was 38.1. serum creatinin was 2.94 mg / dl . endoscopic retrograde cholangio - pancreatography revealed suppurative cholangitis , which was treated by biliary stenting . on admission , the electrocardiogram showed an abnormal pathologic q wave in leads v1 - 2 and a prolonged qt interval ( fig . the troponin t level was elevated at 0.29 ng / dl ( reference level , < 0.01 ng / dl ) , while creatine kinase ( ck ) and ck - mb levels were normal . transthoracic echocardiography ( tte ) revealed that wall motion was abnormal with mid and apical akinesis , and the ejection fraction ( ef ) was estimated to be 12% ( fig . stress - induced cardiomyopathy was diagnosed , and supportive therapy for infection and lv dysfunction was initiated . however , ten days after admission , her mental state was changed into semicoma state . tte revealed mild improvement of the lv systolic function ( ef 44% ) , with a 24  25 mm sized thrombus in the lv apex ( fig . tte performed 7 days after the start of anticoagulant therapy revealed a near normal lv wall motion ( ef 55% ) and complete resolution of the apical thrombus ( fig . takotsubo cardiomyopathy ( stress - induced cardiomyopathy ) is a relatively novel cardiac syndrome characterized by peculiar transient lv dysfunction . approximately 1 - 3% of the patients with stress - induced cardiomyopathy show symptoms that initially mimic acute coronary syndrome.3)5 ) in this case , we did not performed coronary angiography , but we could tentatively diagnose as stress - induced cardiomyopathy because of the absent of cardiovascular symptom and no serial changes of cardiac biomarkers in septic patient . despite the favorable prognosis , certain serious complications have been reported in patients with stress - induced cardiomyopathy , such as acute decompensated heart failure , ventricular arrhythmia , lv rupture , and lv thrombus.4)7 - 12 ) thrombus formation in such cases was probably related to transient apical asynergy combined with increased sympathetic activation , which alters the coagulation cascade . to date , the true incidence and clinical significance of lv thrombus and the related embolic outcomes in patients with stress - induced cardiomyopathy have not been fully established . haghi et al.11 ) reported an 8% incidence of lv thrombus in the study population , but a much lower incidence of accompanying embolic complications . they concluded that lv thrombus can occur at the initial presentation or any time later during the disease . in our patient , the initial echocardiogram 
 showed only apical ballooning and akinesia without any evidence of lv apical thrombus ; however , thrombus formation occurred after a week and led to cerebral infarction . in a systematic review , de gregorio et al.13 ) found that among 15 takotsubo cardiomyopathy patients with ventricular thrombosis , 5 patients suffered from thromboembolic events , 3 of whom developed stroke . therefore , physicians should be aware of this complication . the current treatment of stress - induced cardiomyopathy consists of supportive care and standard treatments for lv systolic dysfunction . the role of anticoagulation therapy has not yet been defined . to the best of our knowledge , there are no published guidelines for the management of stress - induced cardiomyopathy with lv thrombus . however , some reports mention that short - term anticoagulation therapy with heparin and warfarin for several weeks resolved lv thrombus.8)9)11 ) in this case , lv thrombus was resolved after 1 week of anticoagulation therapy . from our review , we conclude that patients with stress - induced cardiomyopathy appear to be at a significant risk for development of thrombus and subsequent stroke because of the marked apical wall motion abnormality . thus , all patients with stress - induced cardiomyopathy should be evaluated for the presence of a ventricular thrombus . we can not observe the lv thrombus even the patients with depressed lv function ; however , we can observe the lv thrombus even the lv function was more improved in follow up echocardiography . the patient did not be followed by echocardiography during 10 days , so we can not clarify when the lv thrombus was developed . the physicians have to keep in mind that frequent echocardiographic follow up should be needed in the cases with stress - induced cardiomyopathy not only a period of markedly reduced lv function but also after clinically improvement . although no specific data exist regarding the role of anticoagulation in stress - induced cardiomyopathy , short - term anticoagulation therapy has been indicated as a treatment for patients with lv thrombus . further research is needed to determine the true incidence of lv thrombus and the role of short - term anticoagulant therapy in patients with stress - induced cardiomyopathy with lv thrombus .
takotsubo cardiomyopathy , also called stress - induced cardiomyopathy , usually occurs in patients with severe emotional or physiologic stress . 
 the prognosis is favorable , and the wall motion abnormlities normalize within weeks . 
 however , stress - induced cardiomyopathy is rarely assosicated with left ventricular thrombus and thromboembolic complications . here 
 , we report a case of stress - induced cardiomyopathy with left ventricular thrombus that embolized to cause cerebral infarction .