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1. ECG of the Week
Dr. PL Chaitanya Varma

2. A 65-year-old man presented with a
Presyncope episode associated with shortness of breath, palpitations, and sweating.
He had a left cerebrovascular accident 2 years previously and was on medication for the same,
No known comorbidities like hypertension and diabetes
On present admission, his blood pressure was 251/138 mmHg and intravenous NTG was initiated and BP
was gradually brought under control.
On the 5th day of hospitalization, he tried to stand up to walk to the toilet, fainted, and collapsed to the floor.
Cardiopulmonary resuscitation was administered for 10 minutes prior to the return of spontaneous circulation.
He was intubated because of a low Glasgow Coma Scale (E1VTM1) score. Inotropic support was started for
hypotension postresuscitation.

3. ECG Post Resuscitation

4. ECG Post Resuscitation
Rate 100/min
Rhythm- Normal Sinus
Rhythm
Tall P wave in II, III,aVF
St elevation in V1V2V3
Reciprocal ST
depression II, III,aVF
T wave inversions
V4V5V6

5. Serial ECG

6. Serial ECG
ST segment elevation in
leads V1–V3 changing to
a right bundle branch
block (RBBB) pattern
[QRS duration > 120ms
RSR’ pattern in V1-2 (“M-
shaped” QRS complex)
Wide, slurred S wave in
lateral leads (I, aVL)]
ST segment elevation in
lead aVR and
widespread deep anterior
T wave inversion

7. Cardiac enzymes were normal

8. CT Brain
Non-enhanced axial computed
tomography of the brain at the level
of the third ventricle reveals diffuse
acute subarachnoid hemorrhage
with intraventricular extension and
communicating hydrocephalus.

9. ● Intracranial hemorrhage has been well described to mimic MI. As such,
inappropriate administration of potent thrombolytic and antiplatelet agents
would no doubt worsen the hemorrhage.
● Intracranial hemorrhage includes intracerebral hemorrhage, subarachnoid
hemorrhage (SAH), and interventricular hemorrhage (IVH).
● The prognosis is extremely poor when there are increases in intracranial
pressure, hydrocephalus, and eventual brain herniation.

10. ● Stress on the nervous system can affect the heart functionally and
structurally, a phenomenon known as neurogenic stress cardiomyopathy
(NSC).
● The NSC occurs frequently in some types of ICHs such as SAH and IPH
(Intraparenchymal Hemorrhage)
● The catecholamine hypothesis, also known as catecholamine-mediated direct
cardiac injury, is the most widely accepted proposed mechanism underlying
the manifestation of NSC, whereby catecholamines directly damage cardiac
tissue.
● The histopathological finding associated with excess catecholamine is
myocardial contract band necrosis.

11. ECG abnormalities that have been described for intracranial hemorrhage, in particular intracerebral hemorrhage and
SAH
● ST-segment elevation or depression
● T wave inversion
● Prolonged QTc interval with large inverted T waves
● Pathological Q waves
● Prominent U waves
● RBBB

13. Thank You