Response Letter: Neurological Disease Triggering Takotsubo Syndrome
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LETTER TO THE EDITOR
Response Letter: Neurological Disease Triggering Takotsubo Syndrome Nicholas A. Morris1, Santosh B. Murthy2,3 and Hooman Kamel2,3* © 2018 Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society
We thank Dr. Finsterer and Dr. Bersano for their interest in our article. We agree that Takotsubo syndrome has been associated with a myriad of neurological conditions, both acute and chronic. Our primary aim was to describe the strength of associations with the most common acute neurological diseases. To this end, we utilized data from 2006 to 2014 from the National Inpatient Sample which is the largest all-payer medical sample in the USA. Dr. Finsterer and Dr. Bersano raise concerns regarding the choice of administrative billing code for our outcome of interest. The National Inpatient Sample included only International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes prior to October 1, 2015 [1]. Indeed, ICD-10-CM billing codes were not in effect prior to 2015. As we limited our search from 2006 to 2014, we would not have missed patients with the ICD-10-CM diagnosis code for Takotsubo cardiomyopathy. Dr. Finsterer and Dr. Bersano also take issue with our inclusion of hypertensive encephalopathy as an acute neurological disorder. They consider hypertensive encephalopathy to be a chronic disease due to chronic arterial hypertension. We counter that the term hypertensive encephalopathy was first introduced in 1928 by Oppenheimer and Fisherberg to designate a syndrome of acute neurological symptoms including seizures,
*Correspondence: [email protected] 3 Department of Neurology, Weill Cornell Medicine, 407 East 61st Street, New York, NY 10065, USA Full list of author information is available at the end of the article
weakness, and aphasia that developed in the setting of a rapid rise in blood pressure in a 19-year-old [2]. In the seminal clinicopathological series by Chester et al. [3] in 1978, hypertensive encephalopathy is defined as “an acute or subacute clinical syndrome that occurs against a background of malignant hypertension—independent of uremia—characterized by signs of diffuse (confusion, drowsiness, headache) rather than focal cerebral dysfunction, and which is often completely reversible.” More recently, acutely elevated blood pressure has been linked to the posterior reversible encephalopathy syndrome which refers to acute neurological symptoms in the setting of reversible subcortical vasogenic brain edema caused by abrupt blood pressure changes or direct effects of cytokines on the endothelium [4]. Thus, we feel that hypertensive encephalopathy justifies its inclusion in our list of acute neurological disorders. Dr. Finsterer and Dr. Bersano astutely point out that our study is limited by its methodology in its ability to determine causation. We agree with this assessment wholeheartedly. Our study only demonstrates an association, not causation. It is possible, as Finsterer and Dr. Bersano point out t
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