Acta Clinica Belgica International Journal of Clinical and Laboratory Medicine
ISSN: 1784-3286 (Print) 2295-3337 (Online) Journal homepage: http://www.tandfonline.com/loi/yacb20
Subarachnoid haemorrhage mimicking transient ST-segment elevation myocardial infarction C.-H. Lai, Y.-H. Juan, S.-L. Chang, W.-L. Lee, C.-K. How & T.-F. Hsu To cite this article: C.-H. Lai, Y.-H. Juan, S.-L. Chang, W.-L. Lee, C.-K. How & T.-F. Hsu (2015) Subarachnoid haemorrhage mimicking transient ST-segment elevation myocardial infarction, Acta Clinica Belgica, 70:4, 304-306, DOI: 10.1179/2295333715Y.0000000019 To link to this article: http://dx.doi.org/10.1179/2295333715Y.0000000019
Published online: 02 Jun 2015.
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Date: 22 March 2016, At: 15:39
Case Report
Subarachnoid haemorrhage mimicking transient ST-segment elevation myocardial infarction C.-H. Lai1,2, Y.-H. Juan3,4, S.-L. Chang2, W.-L. Lee1,2, C.-K. How2,5, T.-F. Hsu2,5 1
Division of Interventional Cardiology, Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan, 2School of Medicine, National Yang-Ming University, Taipei, Taiwan, 3Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou and Chang Gung University, Taoyuan, Taiwan, 4 Healthy Aging Research Center, Chang Gung University, Taiwan, 5Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
Downloaded by [McMaster University] at 15:39 22 March 2016
Patients often present to the emergency department with loss of consciousness. The differential diagnosis of such condition may be difficult because of limited clinical information. The authors present a case of subarachnoid haemorrhage (SAH) with initial electrocardiographic (ECG) finding mimicking ST-segment elevation myocardial infarction (STEMI), which was confirmed to resolve in a follow-up study. Accurate and timely diagnosis of SAH-related ST-segment elevation was important, as the therapeutic strategy for SAH is completely different from that for STEMI. If the clinicians do not have other tools for diagnosis, the follow-up ECG may help us make a most possible diagnosis. Keywords: Intracranial haemorrhage, Myocardial infarction, ST elevation, Coronary spasm, Coma, Loss of conciousness
Introduction Patients often present to the emergency department with loss of consciousness. While the differential diagnosis of loss of consciousness may include intracranial haemorrhage (ICH), myocardial infarction, metabolic disorders, drug overdose, seizure and sepsis, it is often difficult to derive the exact aetiology on initial presentation. The authors present a case of subarachnoid haemorrhage (SAH) with initial electrocardiographic (ECG) finding mimicking ST-segment elevation myocardial infarction (STEMI), which was confirmed to resolve in follow-up study. An ECG finding of ST-segment elevation may include several possible diagnoses, including pulmonary embolism, pericarditis, pulmonary embolism, electrolyte imbalance and ICH.1,2 The possibility of ICH must first be evaluated, because antiplatelet and anticoagulant therapy in STEMI may aggravate the haemorrhage in ICH and resulted in confusion of the exact cause of ICH. Clinicians should recognize this possible presentation in patients presenting with coma and begin immediate search for possible ICH. Emergent coronary catheterization or antiplatelet or
Correspondence to: Teh-Fu Hsu, Department of Emergency Medicine, Taipei Veterans General Hospital, and School of Medicine, National Yang-Ming University, 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan. Email: [email protected]
304
ß Acta Clinica Belgica 2015
DOI 10.1179/2295333715Y.0000000019
anticoagulant agents should be avoided in such patients, as these approaches would further aggravate the severity of ICH and delay the appropriate treatment.
Case Presentation An 80-year-old woman was admitted to our emergency department with comatose at presentation. Physical examination revealed a prompt pupillary light reflex with both pupils of size of 3 mm, an occipital scalp haematoma and flaccid extremities. Electrocardiography showed ST-segment elevation in V2– V5, I, aVL and reciprocal ST-segment depression in the inferior leads, consistent with the typical findings of acute anterolateral STEMI (Fig. 1A). Because of her comatose status, the authors were uncertain whether the STEMI resulted in coma, which caused head trauma or ST-segment change was secondary to the head trauma. Therefore, both follow-up ECG and cranial computed tomography (CT) were arranged. Twenty minutes later, while waiting for the CT, a follow-up ECG revealed complete resolution of the ST-segment elevation, thus allowed us to derive the preliminary diagnosis of ICH-related ST-segment elevation (Fig. 1C). The CT scan revealed bilateral SAH and right subdural haemorrhage with midline shift (Fig. 1B) and supported our preliminary diagnosis. Bedside echocardiography revealed preserved left
Acta Clinica Belgica
2015
VOL .
70
NO .
4
Downloaded by [McMaster University] at 15:39 22 March 2016
Lai et al.
ST-segment elevation in ICH
Figure 1 Serial electrocardiography (ECG) change and non-contrast computed tomography (CT) of the head: (A) ECG on initial presentation showed ST-segment elevation in V2–V5, I, aVL and reciprocal ST-segment depression in the inferior leads, which is consistent with acute anterolateral STEMI (B) Non-contrast CT of the head showed occipital scalp haematoma (arrowhead) with presence of bilateral SAH (thin arrows) and right subdural haemorrhage with midline shift (bold arrow). (C) Follow-up ECG performed 40 minutes after arrival revealed resolution of the prior ST-segment elevation (comparing with A).
ventricular systolic function without apparent wall motion abnormality. Under the impression of ICHrelated ST-segment elevation, emergent coronary catheterization was not performed. However, the patient died within 24 hours of initial presentation because of severe brain oedema.
Discussion There are several possible differential diagnoses of non-ischaemic causes of ST-segment elevation, which included left ventricle hypertrophy, pericarditis, hypothermia, cardioversion, hyperkalemia, Brugada syndrome, antiarrythmic drugs related, normal variant, pulmonary embolism and rarely, ICH (especially SAH).1,2 Moreover, up to 72% abnormalities ECG change occurred in patients with SAH, such as prolongation of QT interval, inversion of T waves, appearance of abnormal U wave, ST-segment depression and ST-segment elevation.3 Theories relating to the underlying cause of ST and T wave changes in SAH are controversial and many mechanisms have been proposed, including abrupt elevation of catecholamine level, neurogenic aetiology and coronary spasm.4 As for our case, because of rapid recovery from the ST-segment elevation, coronary spasm may be the most possible cause. The altered mental status and limited clinical information in our patient was the cause of confusion during the initial evaluation. However, because of the urgent need of door-to-balloon time v90 minutes in STEMI, prompt and accurate differentiation between these two entities is of importance. If the CT was not available at that time and/or head trauma was not so
apparent, control ECG within 15–30 minutes may be an additional tool and help us to make preliminary diagnosis. An increasing ST-segment during the control ECG suggested STEMI, while a fall or normalization of the ST-segment favoured ICH, as shown in our patient. As for the ECG finding, although SAH presenting as ST-segment elevation is rare and difficult to differentiate from the common STEMI, a recent study by Yamashina et al. reported that female gender, preserved left ventricle ejection fraction (w50%) by echocardiogram and ST-segment elevation without reciprocal change favoured SAH-related ST-segment elevation over acute coronary syndrome (P50.03, 0.002, 0.007, respectively).5 Although the reciprocal change was obvious in our patient, SAH-related ST-segment elevation remains the most possible cause, thus signifying the importance of recognizing uncommon presentations of SAH-related ST-segment elevation. Accurate and timely diagnosis of SAH-related ST-segment elevation is important, as the therapeutic strategy for SAH is completely different from that for STEMI. The dual antiplatelet and anticoagulant agents may result in harmful effects in patients with SAH. The reciprocal change in ECG with coexisting SAH should still alert clinicians on possible SAH-related ST-segment elevation. The control ECG with 15–30 minutes may help us make a most possible diagnosis. In conclusion, for patients presenting with coma and ECG revealing possible STEMI, in addition to immediate cranial CT, serial ECGs should also be
Acta Clinica Belgica
2015
VOL .
70
NO .
4
305
Lai et al.
ST-segment elevation in ICH
considered. Although the presence of reciprocal change in ECG often suggested myocardial ischaemia, it can also happen in patients with coexisting SAH. The ECG finding should alert clinicians on possible SAH-related ST-segment elevation and guide appropriate treatment strategy. Emergent coronary catheterization or antiplatelet agents should be avoided in such patients, as these approaches would further aggravate the severity of ICH, while a control ECG within 15–30 minutes may help to confirm the diagnosis.
Disclaimer Statements
Downloaded by [McMaster University] at 15:39 22 March 2016
Contributors The authors would like to assure that all of them have actively participated in the preparation of the manuscript and accepted the contents of the manuscript. All authors contributed significantly in the production of this manuscript and that the authors will sign a statement attesting authorship, disclosing all potential conflicts of interest and releasing the copyright if the manuscript be accepted for publication.
306
Acta Clinica Belgica
2015
VOL .
70
NO .
4
Funding None. Conflict of interest The authors declare that no conflict of interest. Ethics approval This paper is a retrospective case report. There was no occurrence of any personal data in this paper.
References 1 Bailey WB, Chaitman BR. Images in clinical medicine. Electrocardiographic changes in intracranial hemorrhage mimicking myocardial infarction. N Engl J Med. 2003; 349(6):561. 2 Coppola G, Carita P, Corrado E, Borrelli A, Rotolo A, Guglielmo M, Nugara C, Ajello L, Santomauro M, Novo S. ST segment elevations: always a marker of acute myocardial infarction? Indian Heart J. 2013;65(4):412–23. 3 Perron AD, Brady WJ. Electrocardiographic manifestations of CNS events. Am J Emerg Med. 2000;18(6):715–20. 4 Sommargren CE. Electrocardiographic abnormalities in patients with subarachnoid hemorrhage. Am J Crit Care. 2002;11(1):48–56. 5 Yamashina Y, Yagi T, Ishida A, Mibiki Y, Sato H, Nakagawa T, Sato E, Komatsu J. Differentiating between comatose patients resuscitated from acute coronary syndrome-associated and subarachnoid hemorrhage-associated out-of-hospital cardiac arrest. J Cardiol. 2014 http://dx.doi.org/10.1016/j.jjcc. 2014.07.022.
ISSN: 1784-3286 (Print) 2295-3337 (Online) Journal homepage: http://www.tandfonline.com/loi/yacb20
Subarachnoid haemorrhage mimicking transient ST-segment elevation myocardial infarction C.-H. Lai, Y.-H. Juan, S.-L. Chang, W.-L. Lee, C.-K. How & T.-F. Hsu To cite this article: C.-H. Lai, Y.-H. Juan, S.-L. Chang, W.-L. Lee, C.-K. How & T.-F. Hsu (2015) Subarachnoid haemorrhage mimicking transient ST-segment elevation myocardial infarction, Acta Clinica Belgica, 70:4, 304-306, DOI: 10.1179/2295333715Y.0000000019 To link to this article: http://dx.doi.org/10.1179/2295333715Y.0000000019
Published online: 02 Jun 2015.
Submit your article to this journal
Article views: 13
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=yacb20 Download by: [McMaster University]
Date: 22 March 2016, At: 15:39
Case Report
Subarachnoid haemorrhage mimicking transient ST-segment elevation myocardial infarction C.-H. Lai1,2, Y.-H. Juan3,4, S.-L. Chang2, W.-L. Lee1,2, C.-K. How2,5, T.-F. Hsu2,5 1
Division of Interventional Cardiology, Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan, 2School of Medicine, National Yang-Ming University, Taipei, Taiwan, 3Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou and Chang Gung University, Taoyuan, Taiwan, 4 Healthy Aging Research Center, Chang Gung University, Taiwan, 5Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
Downloaded by [McMaster University] at 15:39 22 March 2016
Patients often present to the emergency department with loss of consciousness. The differential diagnosis of such condition may be difficult because of limited clinical information. The authors present a case of subarachnoid haemorrhage (SAH) with initial electrocardiographic (ECG) finding mimicking ST-segment elevation myocardial infarction (STEMI), which was confirmed to resolve in a follow-up study. Accurate and timely diagnosis of SAH-related ST-segment elevation was important, as the therapeutic strategy for SAH is completely different from that for STEMI. If the clinicians do not have other tools for diagnosis, the follow-up ECG may help us make a most possible diagnosis. Keywords: Intracranial haemorrhage, Myocardial infarction, ST elevation, Coronary spasm, Coma, Loss of conciousness
Introduction Patients often present to the emergency department with loss of consciousness. While the differential diagnosis of loss of consciousness may include intracranial haemorrhage (ICH), myocardial infarction, metabolic disorders, drug overdose, seizure and sepsis, it is often difficult to derive the exact aetiology on initial presentation. The authors present a case of subarachnoid haemorrhage (SAH) with initial electrocardiographic (ECG) finding mimicking ST-segment elevation myocardial infarction (STEMI), which was confirmed to resolve in follow-up study. An ECG finding of ST-segment elevation may include several possible diagnoses, including pulmonary embolism, pericarditis, pulmonary embolism, electrolyte imbalance and ICH.1,2 The possibility of ICH must first be evaluated, because antiplatelet and anticoagulant therapy in STEMI may aggravate the haemorrhage in ICH and resulted in confusion of the exact cause of ICH. Clinicians should recognize this possible presentation in patients presenting with coma and begin immediate search for possible ICH. Emergent coronary catheterization or antiplatelet or
Correspondence to: Teh-Fu Hsu, Department of Emergency Medicine, Taipei Veterans General Hospital, and School of Medicine, National Yang-Ming University, 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan. Email: [email protected]
304
ß Acta Clinica Belgica 2015
DOI 10.1179/2295333715Y.0000000019
anticoagulant agents should be avoided in such patients, as these approaches would further aggravate the severity of ICH and delay the appropriate treatment.
Case Presentation An 80-year-old woman was admitted to our emergency department with comatose at presentation. Physical examination revealed a prompt pupillary light reflex with both pupils of size of 3 mm, an occipital scalp haematoma and flaccid extremities. Electrocardiography showed ST-segment elevation in V2– V5, I, aVL and reciprocal ST-segment depression in the inferior leads, consistent with the typical findings of acute anterolateral STEMI (Fig. 1A). Because of her comatose status, the authors were uncertain whether the STEMI resulted in coma, which caused head trauma or ST-segment change was secondary to the head trauma. Therefore, both follow-up ECG and cranial computed tomography (CT) were arranged. Twenty minutes later, while waiting for the CT, a follow-up ECG revealed complete resolution of the ST-segment elevation, thus allowed us to derive the preliminary diagnosis of ICH-related ST-segment elevation (Fig. 1C). The CT scan revealed bilateral SAH and right subdural haemorrhage with midline shift (Fig. 1B) and supported our preliminary diagnosis. Bedside echocardiography revealed preserved left
Acta Clinica Belgica
2015
VOL .
70
NO .
4
Downloaded by [McMaster University] at 15:39 22 March 2016
Lai et al.
ST-segment elevation in ICH
Figure 1 Serial electrocardiography (ECG) change and non-contrast computed tomography (CT) of the head: (A) ECG on initial presentation showed ST-segment elevation in V2–V5, I, aVL and reciprocal ST-segment depression in the inferior leads, which is consistent with acute anterolateral STEMI (B) Non-contrast CT of the head showed occipital scalp haematoma (arrowhead) with presence of bilateral SAH (thin arrows) and right subdural haemorrhage with midline shift (bold arrow). (C) Follow-up ECG performed 40 minutes after arrival revealed resolution of the prior ST-segment elevation (comparing with A).
ventricular systolic function without apparent wall motion abnormality. Under the impression of ICHrelated ST-segment elevation, emergent coronary catheterization was not performed. However, the patient died within 24 hours of initial presentation because of severe brain oedema.
Discussion There are several possible differential diagnoses of non-ischaemic causes of ST-segment elevation, which included left ventricle hypertrophy, pericarditis, hypothermia, cardioversion, hyperkalemia, Brugada syndrome, antiarrythmic drugs related, normal variant, pulmonary embolism and rarely, ICH (especially SAH).1,2 Moreover, up to 72% abnormalities ECG change occurred in patients with SAH, such as prolongation of QT interval, inversion of T waves, appearance of abnormal U wave, ST-segment depression and ST-segment elevation.3 Theories relating to the underlying cause of ST and T wave changes in SAH are controversial and many mechanisms have been proposed, including abrupt elevation of catecholamine level, neurogenic aetiology and coronary spasm.4 As for our case, because of rapid recovery from the ST-segment elevation, coronary spasm may be the most possible cause. The altered mental status and limited clinical information in our patient was the cause of confusion during the initial evaluation. However, because of the urgent need of door-to-balloon time v90 minutes in STEMI, prompt and accurate differentiation between these two entities is of importance. If the CT was not available at that time and/or head trauma was not so
apparent, control ECG within 15–30 minutes may be an additional tool and help us to make preliminary diagnosis. An increasing ST-segment during the control ECG suggested STEMI, while a fall or normalization of the ST-segment favoured ICH, as shown in our patient. As for the ECG finding, although SAH presenting as ST-segment elevation is rare and difficult to differentiate from the common STEMI, a recent study by Yamashina et al. reported that female gender, preserved left ventricle ejection fraction (w50%) by echocardiogram and ST-segment elevation without reciprocal change favoured SAH-related ST-segment elevation over acute coronary syndrome (P50.03, 0.002, 0.007, respectively).5 Although the reciprocal change was obvious in our patient, SAH-related ST-segment elevation remains the most possible cause, thus signifying the importance of recognizing uncommon presentations of SAH-related ST-segment elevation. Accurate and timely diagnosis of SAH-related ST-segment elevation is important, as the therapeutic strategy for SAH is completely different from that for STEMI. The dual antiplatelet and anticoagulant agents may result in harmful effects in patients with SAH. The reciprocal change in ECG with coexisting SAH should still alert clinicians on possible SAH-related ST-segment elevation. The control ECG with 15–30 minutes may help us make a most possible diagnosis. In conclusion, for patients presenting with coma and ECG revealing possible STEMI, in addition to immediate cranial CT, serial ECGs should also be
Acta Clinica Belgica
2015
VOL .
70
NO .
4
305
Lai et al.
ST-segment elevation in ICH
considered. Although the presence of reciprocal change in ECG often suggested myocardial ischaemia, it can also happen in patients with coexisting SAH. The ECG finding should alert clinicians on possible SAH-related ST-segment elevation and guide appropriate treatment strategy. Emergent coronary catheterization or antiplatelet agents should be avoided in such patients, as these approaches would further aggravate the severity of ICH, while a control ECG within 15–30 minutes may help to confirm the diagnosis.
Disclaimer Statements
Downloaded by [McMaster University] at 15:39 22 March 2016
Contributors The authors would like to assure that all of them have actively participated in the preparation of the manuscript and accepted the contents of the manuscript. All authors contributed significantly in the production of this manuscript and that the authors will sign a statement attesting authorship, disclosing all potential conflicts of interest and releasing the copyright if the manuscript be accepted for publication.
306
Acta Clinica Belgica
2015
VOL .
70
NO .
4
Funding None. Conflict of interest The authors declare that no conflict of interest. Ethics approval This paper is a retrospective case report. There was no occurrence of any personal data in this paper.
References 1 Bailey WB, Chaitman BR. Images in clinical medicine. Electrocardiographic changes in intracranial hemorrhage mimicking myocardial infarction. N Engl J Med. 2003; 349(6):561. 2 Coppola G, Carita P, Corrado E, Borrelli A, Rotolo A, Guglielmo M, Nugara C, Ajello L, Santomauro M, Novo S. ST segment elevations: always a marker of acute myocardial infarction? Indian Heart J. 2013;65(4):412–23. 3 Perron AD, Brady WJ. Electrocardiographic manifestations of CNS events. Am J Emerg Med. 2000;18(6):715–20. 4 Sommargren CE. Electrocardiographic abnormalities in patients with subarachnoid hemorrhage. Am J Crit Care. 2002;11(1):48–56. 5 Yamashina Y, Yagi T, Ishida A, Mibiki Y, Sato H, Nakagawa T, Sato E, Komatsu J. Differentiating between comatose patients resuscitated from acute coronary syndrome-associated and subarachnoid hemorrhage-associated out-of-hospital cardiac arrest. J Cardiol. 2014 http://dx.doi.org/10.1016/j.jjcc. 2014.07.022.
