Sudden headache at the gym, now drowsy
The tracing
A 54-year-old woman was lifting weights when she had a sudden, severe occipital headache, the worst of her life. She vomited twice and briefly lost consciousness. She has no chest pain and has never had any.
She is drowsy but obeys commands, GCS 13 (E3 V4 M6). Neck stiffness. Blood pressure 188/102, pulse 78 and regular, saturations 97% on air. Potassium 3.6, magnesium 0.78. High-sensitivity troponin T is 64 ng/L.
The medical registrar looks at the ECG taken in triage and suggests a call to the cath lab.
What does the ECG show, and what should happen next?
Answer
Show the answer and explanation
Sinus rhythm with deep, broad T-wave inversion across the chest leads and a long QT: the "cerebral T wave" pattern of an acute intracranial event. With this history the next test is a CT of the head, not coronary angiography.
- Sinus rhythm at about 78. PR, QRS width and axis are normal.
- Deep, broad T-wave inversion in V1 to V6, deepest in V2, V3 and V6 at around 7 to 8 mm. The limb-lead T waves are low or flat.
- The QT is long, with a QTc around 530 ms.
- No ST elevation and no Q waves.
An abrupt rise in intracranial pressure, classically from aneurysmal subarachnoid haemorrhage but also from large intracerebral haemorrhage and other acute brain injury, drives a surge of sympathetic activity that disturbs repolarisation and can stun the myocardium. The T waves are wide and deep, sometimes giant, prominent U waves may follow. Regional wall-motion abnormality could occur (neurogenic stunned myocardium). The changes usually appear in the first two days and resolve over days to weeks-
Reference
Burch GE, Meyers R, Abildskov JA. A new electrocardiographic pattern observed in cerebrovascular accidents. Circulation. 1954;9(5):719-723. doi:10.1161/01.cir.9.5.719
This tracing was generated, not recorded. It opens in the studio with every dial live.
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