CLINICAL REPORT Takotsubo cardiomyopathy associated with nonepileptic seizure after percutaneous endoscopic lumbar discectomy under general anesthesia Sang-Wook Shin • Seung-Hoon Baek • Bong-Soo Choi • Hyeon-Jeong Lee • Kyoung-Hoon Kim • Eun-Soo Kim Received: 18 November 2009 / Accepted: 12 January 2010 / Published online: 3 April 2010 Ó Japanese Society of Anesthesiologists 2010 Abstract Nonepileptic seizures are rare complication after general anesthesia. Postoperative seizure-induced oxidative stress promotes acute catecholamine toxicity of the myocardium. Takotsubo cardiomyopathy may be more frequent in the perioperative setting than commonly appreciated. We report a case of nonepileptic seizure developed during emergence from general anesthesia. The patient subsequently developed takotsubo cardiomyopathy. We now clearly recognize that patients with seizure activities after general anesthesia may be a higher risk for takotsubo cardiomyopathy. Keywords Nonepileptic seizure Á Takotsubo cardiomyopathy Á General anesthesia Introduction Takotsubo cardiomyopathy is characterized by acute onset of reversible left ventricular (LV) dysfunction, ST-segment elevation, and a minor elevation in serum levels of cardiac enzymes. The condition is usually precipitated by psy- chological or physical stress. Several cases have been reported showing that seizure patients are particularly vulnerable to catecholamine toxicity of the myocardium [1]. We report a case of a nonepileptic seizure that occurred in the operating room while the patient was emerging from general anesthesia. The patient went onto develop takot- subo cardiomyopathy in the intensive care unit. Case history A 67-year-old woman weighing 72 kg visited the neuro- surgical department with severe low back pain that radiated to her right leg. Lumbar disc (L3–L4) herniation was diagnosed, and the patient was scheduled for elective percutaneous endoscopic lumbar discectomy. She had a prior history of hypertension and hypercholesterolemia. Routine premedications (midazolam, 3 mg, IM; glycopyr- rolate, 0.2 mg, IV) were given approximately 30 min before surgery. Anesthesia was induced with 100 mg pro- pofol IV and a 2-mg/h remifentanil IV infusion followed by 50 mg rocuronium IV to facilitate endotracheal intu- bation. Anesthesia was maintained using sevoflurane at 1.0–1.5 minimum alveolar concentration in 50% oxygen and a remifentanil infusion IV at 1.0–2.0 mg/h. The endoscopic lumbar discectomy, which lasted about 2 h, was performed uneventfully. At the end of surgery, after reversal of the residual muscle relaxant effect, the patient resumed spontaneous ventilation with eye opening on command. After extubation, the patient began to exhibit tonic-clonic seizure activity. She became apneic, with oxygen saturations in the 80% range. Vital signs showed a blood pressure of 160–180/80–100 mmHg and a heart rate 80–100 bpm. The anesthesiologist placed an oral airway, which was promptly batted out of position by the patient, after which positive-pressure mask ventilation was per- formed. An arterial blood gas showed a pH of 7.328 partial S.-W. Shin Á S.-H. Baek (&) Á B.-S. Choi Á H.-J. Lee Á K.-H. Kim Á E.-S. Kim Department of Anesthesia and Pain Medicine, Pusan National University School of Medicine, Beomeo-ri, Mulgeum-eup, Yangsan, Gyeongsangnam-do 626-770, Korea e-mail: anebsh@pusan.ac.kr S.-W. Shin Á S.-H. Baek Á H.-J. Lee Á K.-H. Kim Medical Research Institute, Pusan National University Hospital, Yangsan, Korea 123 J Anesth (2010) 24:460–463 DOI 10.1007/s00540-010-0904-7