Electrocardiographic Change Mimicking ST Elevation Myocardial infarction in Subdural Hemorrhage: Diagnostic Dilemma

Author : P.I.N. Sigit, Y. Ahmad
Upload Date : 19-04-2018

Background: A variety of non cardiac conditions had been known to mimic the ECG changes that are seen in acute coronary syndrome. Central nervous system disorders are known to be responsible for the onset of cardiac alterations, frequently observed in the electrocardiogram. Cardiac manifestation of neurologic disorders are common and diverse. Understanding the pathophysiology of cardiac and neurologic disorders is critical for physicians to decide therapies and management.

Case Illustration: A 63-year-old man arrived to the emergency department presenting with deterioration of motor function in his left limbs since two weeks. His electrocardiographic (ECG) showed anterior ST elevation without any complaining of chest pain, breathless and palpitation. The ST elevations in the ECG remained static and the cardiac troponin assay was repeatedly negative. From echocardiography showed concentric left ventricular hypertrophy, normal left ventricular ejection fraction and no abnormality on segmental wall motion. Computed tomography (CT) scans documenting a subdural hemorrhage in the right hemisphere.

Discussion:  Neurogenic cardiac dysfunction due to subdural hemorrhage has not been extensively investigated, but it is likely to be similar to that seen in subarachnoid hemorrhage (SAH). The majority of studies suggest that these ECG abnormalities result from disturbances in the autonomous system due to neurologic disease, promoting a local excess of catecholamines, associated with enhanced adrenal production, and activation of the calcium channels, leading to an increase in cytosolic and mitochondrial calcium, as well as release of free radicals, causing contraction band necrosis and reflected in ECG alterations. The increase in intracranial pressure is also considered a factor in these alterations.

Summary: Holistic analysis should be practiced in diagnosing ST elevation myocardial infraction in patients with intracranial pathologies to obviate a myriad of unnecessary investigations, interventions, costly treatment strategies which may well be detrimental to the patient.

KEYWORDS : Subdural hemorrhage, ST elevation myocardial infarction, ECG change.

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