Noelle Liska, DO
Resident
Medical College of Wisconsin
Wauwatosa, Wisconsin, United States
Anjum Sayyad, MD
Physician
Medical College of Wisconsin
Milwaukee, Wisconsin, United States
A 56-year-old female with electrocardiogram abnormalities after a right posterior communicating artery aneurysm rupture and subarachnoid hemorrhage.
Case Description:
A 56-year-old female patient originally admitted for pneumonia suddenly became obtunded the day prior to her planned discharge home. She was found to have a ruptured aneurysm located in her right posterior communicating artery with a subarachnoid hemorrhage (SAH). She underwent a craniotomy and aneurysmal clipping without complications. She was then admitted for inpatient rehabilitation where a routine electrocardiogram (ECG) was performed. She was found to have several notable ECG changes that were not present prior to her aneurysm rupture including QTc prolongation and giant T-wave inversion in leads I, II, aVL, V2, V3, V4, V5, and V6. The patient underwent a negative cardiac workup and was subsequently followed with serial ECGs as an outpatient. After six months of repeating ECGs there was complete resolution of the QTc prolongation and giant T-wave inversion.
Discussions:
The mechanism of ECG changes following a SAH is not fully understood however occurrences are well documented in the literature. Several ECG changes including those that mimic acute coronary syndrome can occur, such as ST changes and inverted T-waves. The inverted T-waves appear as diffuse, symmetrically inverted, and greater than 10 millimeters. These are also known as giant T-wave inversions or cerebral T-waves. Other ECG changes most frequently observed after a SAH include QTc prolongation, U waves, and R wave abnormalities. Generally, as the neurologic insult resolves, ECG findings normalize. Some reports have shown that persistent QTc prolongation and ST changes are associated with poor clinical outcomes.
Conclusions:
It is important to recognize possible ECG abnormalities within non-cardiac rehabilitation patients. Specifically, noting that some of these changes mimic acute coronary syndrome can help avoid misdiagnoses and possible harm to patients as alternative diagnoses are pursued.
