Journal of Clinical Neuroscience xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Case Report
Subarachnoid hemorrhage mimicking myocardial infarction Felix Benninger ⇑, Guy Raphaeli, Israel Steiner Department of Neurology, Rabin Medical Center, Campus Beilinson, Jabotinsky 39, Petach Tiqva 49000, Israel
a r t i c l e
i n f o
Article history: Received 12 April 2015 Accepted 2 May 2015 Available online xxxx Keywords: Electrocardiogram Headache Subarachnoid haemorrhage Xanthochromia
a b s t r a c t We discuss a patient with an aneurysmal subarachnoid hemorrhage (SAH) presenting with chest pain, electrocardiogram changes compatible with myocardial infarction, and headache. SAH is a medical emergency but an initial misdiagnosis is common, and diagnosis can be delayed due to atypical presentations. The delay of diagnosis of SAH may endanger the life of the patient. Electrocardiogram abnormalities have been described previously in aneurysmal SAH, and can obscure the correct diagnosis. Ó 2015 Elsevier Ltd. All rights reserved.
1. Introduction Subarachnoid hemorrhage (SAH) is a medical emergency but an initial misdiagnosis is common, and diagnosis can be delayed due to atypical presentations. The delay of diagnosis of SAH may endanger the life of the patient. Electrocardiogram abnormalities have been described previously in aneurysmal SAH, and can obscure the correct diagnosis.
artery. For treatment, a remodeling technique was chosen with stent-assisted coiling, consisting of implantation of a braided cell, self-expansible stent (3.5 30 mm) in front of the neck in the supra-clinoid internal carotid artery segment, combined with detachment of three coils into the aneurysmal sac. The procedure was uneventful and the patient was awakened with no focal deficits. In the following days, no signs of vasospasm were detected, and she was discharged home 2 weeks after her admission but was advised to postpone her return to weight lifting.
2. Case report 3. Discussion A 75-year-old woman with a medical history of heart burn, presented to our emergency department (ED) 4 days after the acute onset of chest pain and excruciating headaches during routine exercise lifting weights. The left sided chest pains had a waxing and waning character, without radiation into her arm or jaw. She described the headache as thunderclap-like in the beginning, with a slight improvement for the last 2 days. In the ED, her neurologic exam was normal with no neck stiffness. On an electrocardiogram, ST-segment elevation was present but her troponin levels were in the normal range (Fig. 1A). A head CT scan without contrast was performed, which did not show active bleeding or other pathologies. Due to the sudden onset of the headache, a lumbar puncture was performed and red blood cells and xanthochromia were present, confirming the diagnosis of SAH (Fig. 1B). On a subsequent CT angiogram, an aneurysm of the left posterior communicating artery was detected (Fig. 1C). On angiography it was seen to be a small, wide-neck blister aneurysm of the posterior communicating ⇑ Corresponding author. Tel.: +972 526756300; fax: +972 39378220. E-mail address: [email protected] (F. Benninger).
SAH from the rupture of an intracranial aneurysm is a neurologic emergency. The fatality rate of SAH is decreasing, but about one quarter of patients succumb in the first 24 hours and of those surviving, almost half will have long term cognitive impairment [1–3]. The immediate recognition of SAH in the ED is crucial for the right choice of therapy. The anamnestic clues are most important, and the level of suspicion for SAH needs to be high as an initial misdiagnosis is common [4,5]. The association of electrocardiogram abnormalities and aneurysmal SAH has been recognized previously. The most common changes have been described as involving the QT-interval, T-wave, and ST-segment [6,7]. These electrocardiogram changes can mimic acute ischemic heart disease, and might delay the correct diagnosis. It has been postulated that increased central sympathetic activity, possibly by activation of the hypothalamus, causes a hyperdynamic cardiovascular state that is responsible for the electrocardiogram changes [8]. Electrocardiogram changes in SAH were commonly regarded as benign [9,10], but have been associated with a higher mortality and as a predictor of vasospasm after SAH [11,12]
http://dx.doi.org/10.1016/j.jocn.2015.05.031 0967-5868/Ó 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Benninger F et al. Subarachnoid hemorrhage mimicking myocardial infarction. J Clin Neurosci (2015), http://dx.doi.org/ 10.1016/j.jocn.2015.05.031
2
Case Report / Journal of Clinical Neuroscience xxx (2015) xxx–xxx
Fig. 1. ST-elevations present on the electrocardiogram (A). Cerebrospinal fluid tainted with red blood cells and xanthochromia (B). A 3D reconstruction of the CT angiogram showing a small, wide neck blister aneurysm of the posterior communicating artery (Pcom), treated by a remodeling technique with stent-assisted coiling, combined with detachment of three coils into the sac (C). MCA = middle cerebral artery. This figure is available in colour at www.sciencedirect.com.
Myocardial stunning as been described in stroke patients and several case reports of SAH, and might play a crucial role in explaining the electrocardiogram changes [13–15]. Rarely, as in our patient, these changes are visible for more then 72 hours [6]. Thrombolytic therapy or a delay of diagnosis of SAH and withholding of lifesaving neurosurgery in such patients, may have serious and/or fatal consequences. Conflicts of Interest/Disclosures The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication. References [1] Suarez JI, Tarr RW, Selman WR. Aneurysmal subarachnoid hemorrhage. N Engl J Med 2006;354:387–96. [2] Hackett ML, Anderson CS. Health outcomes 1 year after subarachnoid hemorrhage: an international population-based study. The Australian Cooperative Research on Subarachnoid Hemorrhage Study Group. Neurology 2000;55:658–62. [3] Hop JW, Rinkel GJ, Algra A, et al. Case-fatality rates and functional outcome after subarachnoid hemorrhage: a systematic review. Stroke 1997;28:660–4. [4] Kowalski RG, Claassen J, Kreiter KT, et al. Initial misdiagnosis and outcome after subarachnoid hemorrhage. JAMA 2004;291:866–9.
[5] Edlow JA, Caplan LR. Avoiding pitfalls in the diagnosis of subarachnoid hemorrhage. N Engl J Med 2000;342:29–36. [6] Brouwers PJ, Wijdicks EF, Hasan D, et al. Serial electrocardiographic recording in aneurysmal subarachnoid hemorrhage. Stroke 1989;20:1162–7. [7] Salvati M, Cosentino F, Artico M, et al. Electrocardiographic changes in subarachnoid hemorrhage secondary to cerebral aneurysm. Report of 70 cases. Ital J Neurol Sci 1992;13:409–13. [8] Mayer SA, Lin J, Homma S, et al. Myocardial injury and left ventricular performance after subarachnoid hemorrhage. Stroke 1999;30:780–6. [9] Gascón P, Ley TJ, Toltzis RJ, et al. Spontaneous subarachnoid hemorrhage simulating acute transmural myocardial infarction. Am Heart J 1983;105:511–3. [10] Beard EF, Robertson JW, Robertson RC. Spontaneous subarachnoid hemorrhage simulating acute myocardial infarction. Am Heart J 1959;58:755–9. [11] Sakr YL, Lim N, Amaral AC, et al. Relation of ECG changes to neurological outcome in patients with aneurysmal subarachnoid hemorrhage. Int J Cardiol 2004;96:369–73. [12] Ibrahim GM, Macdonald RL. Electrocardiographic changes predict angiographic vasospasm after aneurysmal subarachnoid hemorrhage. Stroke 2012;43:2102–7. [13] Murthy SB, Shah S, Venkatasubba Rao CP, et al. Clinical characteristics of myocardial stunning in acute stroke. J Clin Neurosci 2014;21:1279–82. [14] Murthy SB, Shah S, Rao CPV, et al. Neurogenic stunned myocardium following acute subarachnoid hemorrhage: pathophysiology and practical considerations. J Intensive Care Med 2013 [Epub ahead of print]. [15] Donaldson JW, Pritz MB. Myocardial stunning secondary to aneurysmal subarachnoid hemorrhage. Surg Neurol 2001;55:12–6 [discussion 16].
Please cite this article in press as: Benninger F et al. Subarachnoid hemorrhage mimicking myocardial infarction. J Clin Neurosci (2015), http://dx.doi.org/ 10.1016/j.jocn.2015.05.031
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Case Report
Subarachnoid hemorrhage mimicking myocardial infarction Felix Benninger ⇑, Guy Raphaeli, Israel Steiner Department of Neurology, Rabin Medical Center, Campus Beilinson, Jabotinsky 39, Petach Tiqva 49000, Israel
a r t i c l e
i n f o
Article history: Received 12 April 2015 Accepted 2 May 2015 Available online xxxx Keywords: Electrocardiogram Headache Subarachnoid haemorrhage Xanthochromia
a b s t r a c t We discuss a patient with an aneurysmal subarachnoid hemorrhage (SAH) presenting with chest pain, electrocardiogram changes compatible with myocardial infarction, and headache. SAH is a medical emergency but an initial misdiagnosis is common, and diagnosis can be delayed due to atypical presentations. The delay of diagnosis of SAH may endanger the life of the patient. Electrocardiogram abnormalities have been described previously in aneurysmal SAH, and can obscure the correct diagnosis. Ó 2015 Elsevier Ltd. All rights reserved.
1. Introduction Subarachnoid hemorrhage (SAH) is a medical emergency but an initial misdiagnosis is common, and diagnosis can be delayed due to atypical presentations. The delay of diagnosis of SAH may endanger the life of the patient. Electrocardiogram abnormalities have been described previously in aneurysmal SAH, and can obscure the correct diagnosis.
artery. For treatment, a remodeling technique was chosen with stent-assisted coiling, consisting of implantation of a braided cell, self-expansible stent (3.5 30 mm) in front of the neck in the supra-clinoid internal carotid artery segment, combined with detachment of three coils into the aneurysmal sac. The procedure was uneventful and the patient was awakened with no focal deficits. In the following days, no signs of vasospasm were detected, and she was discharged home 2 weeks after her admission but was advised to postpone her return to weight lifting.
2. Case report 3. Discussion A 75-year-old woman with a medical history of heart burn, presented to our emergency department (ED) 4 days after the acute onset of chest pain and excruciating headaches during routine exercise lifting weights. The left sided chest pains had a waxing and waning character, without radiation into her arm or jaw. She described the headache as thunderclap-like in the beginning, with a slight improvement for the last 2 days. In the ED, her neurologic exam was normal with no neck stiffness. On an electrocardiogram, ST-segment elevation was present but her troponin levels were in the normal range (Fig. 1A). A head CT scan without contrast was performed, which did not show active bleeding or other pathologies. Due to the sudden onset of the headache, a lumbar puncture was performed and red blood cells and xanthochromia were present, confirming the diagnosis of SAH (Fig. 1B). On a subsequent CT angiogram, an aneurysm of the left posterior communicating artery was detected (Fig. 1C). On angiography it was seen to be a small, wide-neck blister aneurysm of the posterior communicating ⇑ Corresponding author. Tel.: +972 526756300; fax: +972 39378220. E-mail address: [email protected] (F. Benninger).
SAH from the rupture of an intracranial aneurysm is a neurologic emergency. The fatality rate of SAH is decreasing, but about one quarter of patients succumb in the first 24 hours and of those surviving, almost half will have long term cognitive impairment [1–3]. The immediate recognition of SAH in the ED is crucial for the right choice of therapy. The anamnestic clues are most important, and the level of suspicion for SAH needs to be high as an initial misdiagnosis is common [4,5]. The association of electrocardiogram abnormalities and aneurysmal SAH has been recognized previously. The most common changes have been described as involving the QT-interval, T-wave, and ST-segment [6,7]. These electrocardiogram changes can mimic acute ischemic heart disease, and might delay the correct diagnosis. It has been postulated that increased central sympathetic activity, possibly by activation of the hypothalamus, causes a hyperdynamic cardiovascular state that is responsible for the electrocardiogram changes [8]. Electrocardiogram changes in SAH were commonly regarded as benign [9,10], but have been associated with a higher mortality and as a predictor of vasospasm after SAH [11,12]
http://dx.doi.org/10.1016/j.jocn.2015.05.031 0967-5868/Ó 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Benninger F et al. Subarachnoid hemorrhage mimicking myocardial infarction. J Clin Neurosci (2015), http://dx.doi.org/ 10.1016/j.jocn.2015.05.031
2
Case Report / Journal of Clinical Neuroscience xxx (2015) xxx–xxx
Fig. 1. ST-elevations present on the electrocardiogram (A). Cerebrospinal fluid tainted with red blood cells and xanthochromia (B). A 3D reconstruction of the CT angiogram showing a small, wide neck blister aneurysm of the posterior communicating artery (Pcom), treated by a remodeling technique with stent-assisted coiling, combined with detachment of three coils into the sac (C). MCA = middle cerebral artery. This figure is available in colour at www.sciencedirect.com.
Myocardial stunning as been described in stroke patients and several case reports of SAH, and might play a crucial role in explaining the electrocardiogram changes [13–15]. Rarely, as in our patient, these changes are visible for more then 72 hours [6]. Thrombolytic therapy or a delay of diagnosis of SAH and withholding of lifesaving neurosurgery in such patients, may have serious and/or fatal consequences. Conflicts of Interest/Disclosures The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication. References [1] Suarez JI, Tarr RW, Selman WR. Aneurysmal subarachnoid hemorrhage. N Engl J Med 2006;354:387–96. [2] Hackett ML, Anderson CS. Health outcomes 1 year after subarachnoid hemorrhage: an international population-based study. The Australian Cooperative Research on Subarachnoid Hemorrhage Study Group. Neurology 2000;55:658–62. [3] Hop JW, Rinkel GJ, Algra A, et al. Case-fatality rates and functional outcome after subarachnoid hemorrhage: a systematic review. Stroke 1997;28:660–4. [4] Kowalski RG, Claassen J, Kreiter KT, et al. Initial misdiagnosis and outcome after subarachnoid hemorrhage. JAMA 2004;291:866–9.
[5] Edlow JA, Caplan LR. Avoiding pitfalls in the diagnosis of subarachnoid hemorrhage. N Engl J Med 2000;342:29–36. [6] Brouwers PJ, Wijdicks EF, Hasan D, et al. Serial electrocardiographic recording in aneurysmal subarachnoid hemorrhage. Stroke 1989;20:1162–7. [7] Salvati M, Cosentino F, Artico M, et al. Electrocardiographic changes in subarachnoid hemorrhage secondary to cerebral aneurysm. Report of 70 cases. Ital J Neurol Sci 1992;13:409–13. [8] Mayer SA, Lin J, Homma S, et al. Myocardial injury and left ventricular performance after subarachnoid hemorrhage. Stroke 1999;30:780–6. [9] Gascón P, Ley TJ, Toltzis RJ, et al. Spontaneous subarachnoid hemorrhage simulating acute transmural myocardial infarction. Am Heart J 1983;105:511–3. [10] Beard EF, Robertson JW, Robertson RC. Spontaneous subarachnoid hemorrhage simulating acute myocardial infarction. Am Heart J 1959;58:755–9. [11] Sakr YL, Lim N, Amaral AC, et al. Relation of ECG changes to neurological outcome in patients with aneurysmal subarachnoid hemorrhage. Int J Cardiol 2004;96:369–73. [12] Ibrahim GM, Macdonald RL. Electrocardiographic changes predict angiographic vasospasm after aneurysmal subarachnoid hemorrhage. Stroke 2012;43:2102–7. [13] Murthy SB, Shah S, Venkatasubba Rao CP, et al. Clinical characteristics of myocardial stunning in acute stroke. J Clin Neurosci 2014;21:1279–82. [14] Murthy SB, Shah S, Rao CPV, et al. Neurogenic stunned myocardium following acute subarachnoid hemorrhage: pathophysiology and practical considerations. J Intensive Care Med 2013 [Epub ahead of print]. [15] Donaldson JW, Pritz MB. Myocardial stunning secondary to aneurysmal subarachnoid hemorrhage. Surg Neurol 2001;55:12–6 [discussion 16].
Please cite this article in press as: Benninger F et al. Subarachnoid hemorrhage mimicking myocardial infarction. J Clin Neurosci (2015), http://dx.doi.org/ 10.1016/j.jocn.2015.05.031
