Electrocardiographic changes mimicking acute coronary syndrome in a large intracranial tumour: A diagnostic dilemma

Abstract

BackgroundST elevation Myocardial infarction is a medical emergency. A variety of noncardiac conditions had been known to mimic the ECG changes that are seen in acute coronary syndrome. Although the common ECG changes that are documented with raised intracranial pressure are T inversions, prolongation of QT interval and sinus bradycardia, ST elevation or depression, arrhythmias and prominent U waves have also been recognized. However, ST elevations in association with primary intracranial tumours are rarely reported.Case presentationA 68-year-old female patient with a large left sided frontoparietal sphenoidal ridge meningioma with mass effect developed sudden onset shortness of breath while awaiting surgery. Her ECG showed ST segment elevations in the inferior leads along with reciprocal T inversions in anterior leads. The patient was treated with dual antiplatelet therapy and unfractionated heparin. The ST elevations in the ECG remained static and the cardiac Troponin assay was repeatedly negative. 2D ECHO, coronary angiogram and CT pulmonary angiography were normal. The repeat noncontract CT scan of the brain revealed two small areas of haemorrhage in the tumour.ConclusionThe two mechanisms for ECG changes described in subarachnoid haemorrhage are the neurogenic stunned myocardium due to the catecholamine surge on the myocytes and stress cardiomyopathy. The same mechanisms could be the reasons for the ECG changes seen in intracranial tumours. These ECG changes could be easily misdiagnosed as acute coronary syndrome. This case emphasizes the importance of the cardiac biomarkers, 2D ECHO and coronary angiogram when confronted with such a diagnostic dilemma. Thus a more holistic analysis should be practiced in diagnosing acute coronary events in patients with intracranial pathologies to obviate a myriad of unnecessary investigations, interventions, costly treatment strategies which may well be detrimental to the patient.

Electrocardiographic changes in patients with raised intracranial pressure from supratentorial brain tumors

“…reported a case of frontoparietal meningioma where ST elevation in inferior leads prompted management with antiplatelet therapy and unfractionated heparin. [ 9 ] Interestingly, there was no concomitant troponin elevation, and the ECG changes persisted despite the treatment with heparin. This was further complicated by hemorrhage into the tumor and worsening of GCS.…”

“…[ 1 , 6 - 8 ] Some of these changes, such as ST-segment elevation/depression, may be indistinguishable from those seen in patients with an acute myocardial ischemic event. [ 1 , 8 , 9 ] Therefore, it is of paramount importance that the clinician is able to distinguish the ECG changes caused by neurological conditions from that of ischemic heart disease.…”

The Irreversible Neurogenic Stress Cardiomyopathy During Large Supratentorial Brain Tumor Resection

“…NSC is expressed in EKG signs or in left ventricular wall motion abnormalities, the release of a myocardial necrosis enzyme and an increased BNP. In electrocardiography, differences with QT interval prolongation, ST segment depression, long QT syndrome, T-wave inversion and plenty of arrhythmias in NSC have been recognized [9, 10]. In the studies ( n = 32), ST elevation was found in 53.1% of patients with TC whereas ST-depression/negative T with 43.8% [2].…”

Electrocardiogram Changes in Intracranial Space Occupying Lesion

“…Intracranial pathologies such as hemorrhage, aneurysm, stroke, injury, or a space-occupying lesion, have been reported to cause ECG changes mimicking acute coronary syndrome. [1][2][3] These changes are poorly understood and thought to occur due to altered sympathetic tone and associated catecholamine surge. 2 Though there are reports mentioning the appearance of ECG changes during acute neurological stress, this is an interesting case wherein an American Society of Anesthesiologists (ASA) grade 1 patient with mass effect came for elective surgery developed ECG abnormalities despite her normal physical status and no suggestive history.…”

“…[1][2][3] These changes are poorly understood and thought to occur due to altered sympathetic tone and associated catecholamine surge. 2 Though there are reports mentioning the appearance of ECG changes during acute neurological stress, this is an interesting case wherein an American Society of Anesthesiologists (ASA) grade 1 patient with mass effect came for elective surgery developed ECG abnormalities despite her normal physical status and no suggestive history. The common reported ECG findings mimic acute coronary syndrome with ST elevation and T inversion with signs and symptoms of neurogenic stunned myocardium such as chest pain, shortness of breath, and hemodynamic instability.…”