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The brain of STEMI

      1. Introduction

      An 83 y/o African American male with a history of hypertension and chronic kidney disease presented following a fall. The fall occurred while he was trying to get up from a sitting position. The patient said he was light-headed and his knees gave way, but at the time of history taking he was asymptomatic. He said he remembered the fall and did not lose consciousness. On presentation his vitals were normal. There were no signs of significant trauma or focal neurological deficits. His initial electrocardiogram (EKG) demonstrated sinus rhythm, rate of 89 beats/min, prolonged QT interval, diffuse arrowhead T wave inversions, and minimal ST segment elevation in lead V1-3 which was alarming for ST segment elevation myocardial infarction (STEMI) (Fig. 1). On laboratory data D dimer was 0.78 mg/dl (normal 0.19–0.49 mg/dl), creatinine 2.3 mg/dl, and first troponin 0.67 mg/dl (normal <0.045 mg/dl). Transthoracic 2-dimensional echocardiogram (TTE) showed normal left ventricular systolic function with grade 1 diastolic dysfunction and no regional wall motion abnormality. Ventilation perfusion scan was low probability for pulmonary embolism.
      Figure thumbnail gr1
      Fig. 1Electrocardiogram demonstrating prolonged QT interval, diffuse arrowhead T wave inversions, and minimal ST segment elevation in lead V1-3.
      What is the diagnosis?

      2. Diagnosis

      Based on the patient's history and persistent diffuse arrow head T wave inversion on electrocardiogram we ordered computed tomography (CT) scan of the brain which showed a subacute right frontoparietal subdural hematoma. This leads to a diagnosis of subdural hemorrhage leading to abnormal EKG. Troponins trended down from an initial value of 0.67 nm/ml to 0.49 nm/ml and 0.34 nm/ml. The patient was thought to be a good candidate for watchful conservative management and follow up CT scan demonstrated improvement of the subdural hematoma. The patient was later discharged in stable condition and demonstrated improvement in his T wave inversions that time.
      A 2.3% incidence of alternative conditions mimicking STEMI is found in patients referred for primary percutaneous coronary intervention (PCI) [
      • Gu Y.L.
      • et al.
      Conditions mimicking acute ST-segment elevation myocardial infarction in patients referred for primary percutaneous coronary intervention.
      ]. The electrocardiographic changes in patients with non-ischemic STEMI mimics which have been reported are mostly transient [
      • Yu A.C.
      • Riegert-Johnson D.L.
      A case of acute pancreatitis presenting with electrocardiographic signs of acute myocardial infarction.
      ,
      • Makaryus A.N.
      • Adedeji O.
      • Ali S.K.
      Acute pancreatitis presenting as acute inferior wall ST-segment elevations on electrocardiography.
      ]. The EKG changes in these patients are hypothesized to be secondary to changes in vagal tone, cardio-biliary reflex, release of pancreatic proteolytic enzymes causing myonecrosis, transient coronary vasospasm, and associated metabolic disturbances [
      • Yu A.C.
      • Riegert-Johnson D.L.
      A case of acute pancreatitis presenting with electrocardiographic signs of acute myocardial infarction.
      ,
      • Makaryus A.N.
      • Adedeji O.
      • Ali S.K.
      Acute pancreatitis presenting as acute inferior wall ST-segment elevations on electrocardiography.
      ]. These EKG changes usually resolve with the treatment of the underlying condition.
      This report demonstrates the need for physicians to be aware of changes in EKG and troponin in cases of intracerebral pathologies. Nonischemic causes should be excluded even in patients with increased cardiac specific markers such as troponin.

      Conflict of interests

      The authors state that they have no conflicts of interest.

      References

        • Gu Y.L.
        • et al.
        Conditions mimicking acute ST-segment elevation myocardial infarction in patients referred for primary percutaneous coronary intervention.
        Neth Heart J. 2008; 16: 325-331
        • Yu A.C.
        • Riegert-Johnson D.L.
        A case of acute pancreatitis presenting with electrocardiographic signs of acute myocardial infarction.
        Pancreatology. 2003; 3: 515-517
        • Makaryus A.N.
        • Adedeji O.
        • Ali S.K.
        Acute pancreatitis presenting as acute inferior wall ST-segment elevations on electrocardiography.
        Am J Emerg Med. 2008; 26 (p. 734.e1–4)