Heart-Brain axis: is microvascular dysfunction the link between stroke and Takotsubo syndrome?

Takotsubo syndrome (TS) is characterized by transient left ventricular dysfunction, often triggered by psychological or physiological stress. Increasing evidence highlights the critical role of the brain-heart axis in TS, with small blood vessels acting as central mediators. Recent data indicate a significant association between TS and cerebrovascular events, particularly ischemic stroke. Studies show that the incidence of stroke in TS patients is 1-2% per patient-year, which may occur during the acute phase or later due to ongoing autonomic and microvascular dysfunction. This underscores the shared mechanisms of microvascular impairment between the heart and brain in TS. Imaging techniques are essential for detecting microvascular abnormalities in both the heart and brain, providing valuable insights into the interconnected nature of microvascular dysfunction across the heart-brain axis. The aim of this review is to investigate the potential shared pathophysiological mechanisms that link TS and stroke, with a specific emphasis on microvascular dysfunction as a common factor. By examining the role of the heart-brain axis in both conditions and emphasizing the crucial role of advanced imaging techniques, this review seeks to clarify how microvascular abnormalities can simultaneously affect the cardiovascular and cerebrovascular systems. Additionally, it provides insights into the clinical implications of these findings, highlighting the importance of viewing TS and stroke as interconnected conditions within a shared pathological framework. Understanding these mechanisms may not only improve early detection but also pave the way for novel therapeutic strategies targeting both cardiac and cerebral microvascular health, potentially enhancing outcomes for TS patients.