CASE PRESENTATION: A 19 year old female was given tPA for acute aphasia and right sided hemiparesis. Her past medical history was significant for lower extremity weakness, elevated CK, and a muscle biopsy showing noninflammatory myopathy. In order to obtain an MRI brain, the patient required anesthesia because of excessive movement and agitation. She consequently experienced hypotention, tachycardia, worsening aphasia, and hemiparesis. Labs showed leukocytosis, lactic acidosis, and elevated CK. She was transferred to the MICU and bedside ultrasound demonstrated a severely reduced left ventricular function. She was promptly intubated and underwent ECMO. A myocardial biopsy with mitochondrial DNA analysis revealed an A-to-G transition in the tRNA at the nucleotide position of 3243. This was consistent with MELAS syndrome. The patient was given an LVAD and is currently awaiting a heart transplant.