Answer

Cerebrovascular disease–induced T-wave inversion: The ECG demonstrates a

sinus rhythm of 60 bpm with a prolonged QT interval of 680 msec and deep,
symmetric T-wave inversion in leads I-III, AVF, and V2-V6. Head CT
demonstrated bilateral, frontal subdural hemorrhages (see Image 2). The
patient was admitted to the intensive care unit for medical treatment.

Acute myocardial infarction often occurs in the setting of acute stroke. However,
the diagnosis of myocardial infarction is complicated by the fact that clinical
symptoms such as chest pain may not accompany myocardial damage in acute
stroke. In addition, the stress of acute stroke may cause nonspecific elevations
of the biochemical markers of myocardial damage, as well as various ECG
abnormalities consistent with early repolarization and ischemic-like changes.
Repolarization, ischemic-like ECG changes, and/or QT prolongation are found
in approximately 75% of patients with subarachnoid hemorrhage, irrespective of
a history of heart disease. Similar changes are present in more than 90% of
unselected patients with ischemic stroke or intracerebral hemorrhage, but the
prevalence decreases if patients with preexisting heart disease are excluded.
Other methods for diagnosing acute myocardial injury are necessary for a
definitive diagnosis. Examples of such methods are echocardiography to detect
cardiac-wall motion, laboratory tests to detect elevated levels of biochemical
markers of myocardial injury, autopsy, and thallium scintigraphy.

Acute cerebrovascular disease can produce ECG changes, including ST-

segment and T-wave changes similar to those associated with cardiac
ischemia. A prolonged QRS complex, an increased QT interval, and prominent
peaked or deeply inverted and symmetric T waves are commonly seen. The
changes can occur soon after the neurologic event, or they can evolve over a
few days. In patients with intracranial hemorrhage, T-wave inversion is not an
isolated ECG anomaly; it might also be associated with ventricular contraction
abnormalities demonstrable on follow-up echocardiograms or cardiac perfusion
studies. Several mechanisms have been suggested to explain the acute
reversible cardiac injury, including microvascular spasm and increased levels of
circulating catecholamines.

For more information on cerebrovascular disease–induced T-wave inversion,

see the eMedicine articles Subdural Hematoma (within the Radiology specialty)
and Intracranial Hemorrhage (within the Neurology specialty).

References
 Kasper DL, Braunwald E, Fauci A, Hauser S, Longo D, Jameson JL, eds.
Harrison's Principles of Internal Medicine.16th ed. New York, NY:
McGraw-Hill Professional; 2005.

 Sharkey SW, Shear W, Hodges M, Herzog CA. Reversible myocardial

contraction abnormalities in patients with an acute noncardiac illness.
Chest 1998;114(1):98-105.

BACKGROUND
An 81-year-old woman presents to the emergency department with altered
mentation. The patient was in her usual state of health until today, when she
vomited on several occasions. The vomiting was attributed to her family's
discontinuation of her metoclopramide (Reglan) therapy because they were
concerned that this medication was aggravating her facial dyskinesia. Today,
the patient was noted to have difficulty communicating (both understanding and
verbalizing), and she was unable to move her left upper extremity. She has a
medical history of end-stage renal disease requiring hemodialysis, insulin-
dependent diabetes mellitus, and coronary artery disease with hypertension.
She takes insulin, sevelamer hydrochloride (Renagel), simvastatin, labetalol,
and enalapril.

On physical examination, the patient appears ill, with temperature of 98.4°F,

blood pressure of 180/89 mm Hg, heart rate of 72 bpm, and respiratory rate of
14 breaths per minute. Her oxygenation is 96% on room air. Findings on
pulmonary, cardiac, and abdominal examination are benign, but she is aphasic
and has left hemiparesis on the neurologic examination. Her finger-stick blood
glucose level is 112 mg/dL.

ECG is ordered (see Image).

What is the diagnosis?

Hint
Try to localize the abnormality.

Authors: Gil Z. Shlamovitz, MD,

Department of Emergency
Medicine, UCLA Medical Center,
Los Angeles, Calif, David Geffen
School of Medicine at UCLA

Rick Kulkarni, MD, Attending

Physician, Department of
Emergency Medicine, Olive View
- UCLA Medical Center, Assistant
Professor of Medicine, David
Geffen School of Medicine at
UCLA

eMedicine Editor:
John Vozenilek, MD, Division of
Emergency Medicine, Evanston
Northwestern Healthcare