Electrocardiographic changes mimicking acute coronary syndrome in a large intracranial tumour: A diagnostic dilemma
© The Author(s). 2017
Received: 16 November 2016
Accepted: 29 March 2017
Published: 4 April 2017
ST 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.
A 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.
The 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.
KeywordsInferior ST segment elevated myocardial infarction Intracranial tumour ECG changes
Myocardial infarction (MI) is defined as a clinical or pathological event due to myocardial ischaemia causing myocardial injury or necrosis. The electrocardiogram (ECG) is the mainstay in the initial diagnosis of patients with suspected acute coronary syndrome (ACS). ST elevation myocardial infarction (STEMI) is a medical emergency, as the beneficial effects of therapy with reperfusion are greatest when performed early. But a variety of noncardiac conditions have been known to mimic the ECG changes seen in ACS. It is well recognized that certain neurological diseases present with such alterations in the ECG. The common ECG changes that are documented with raised intracranial pressure are T inversions, prolongation of QT interval and sinus bradycardia. Yet ST elevation or depression, arrhythmias, neurogenic T waves, J waves and prominent U waves have all been recognized [1–4].
However the occurrence of ST elevations in association with primary intracranial tumours is not a frequent finding in the literature. We intend to report a patient with a large meningioma presenting with ST elevations in the inferior leads on ECG with no echocardiographic (ECHO) or coronary angiographic evidence of myocardial infarction.
ACS is due to ischaemia of the cardiac muscles and is a medical emergency. The first step in the management is prompt recognition with proper history taking along with an ECG and cardiac biomarkers. Despite of the variety of diagnostic tests available, the ECG remains the mainstay in the initial diagnosis, categorization and the localization of the vascular territory in patients with suspected ACS. Furthermore a recent meta-analysis had suggested that presence of ST segment elevation in lead aVR as a powerful predictor of left main coronary disease and triple vessel disease . Our patient had ST segment elevations confined to the inferior leads on ECG. However there had been numerous studies that concluded that there could be a myriad of ECG changes in association with raised intra cranial pressure.
A study conducted among a group of patients with elevated intracranial pressure (ICP) but without cardiac comorbidities revealed ECG changes such as ST segment elevation, T wave inversion, shortening or prolongation of QT interval, prominent U waves and notched T waves. The ICP was monitored using Konigsburg extradural transducer and the ECG changes reverted with the reduction in ICP .
Although the repolarisation abnormalities in ECG are more frequent after subarachnoid hemorrhages (SAH) they are also reported in brain tumours. It is believed that such changes are generally reversible and the prognostic value is limited . The two mechanisms described for the ECG changes in SAH are the neurogenic stunned myocardium due to the catecholamine surge on the myocytes  and stress cardiomyopathy . However the exact mechanisms for ST segment elevations in intracranial tumours is unclear.
There had been very few cases of intracranial tumours reported presenting with ST segment elevation. Povoa and Cavichio had concluded in a study done in Brazil that 2 out of 66 patients with intracranial tumours (3%) had ST segment elevations on ECG . Hersch concluded in another study done in South Africa that 3 out of 20 (15%) patients with intracranial space occupying lesions including tumours, cerebral abscesses, subdural haematoma and tuberculoma had significant ST segment elevation in precordial leads .
Furthermore there had been ECG changes associated with perioperative periods of intracranial tumours . Nevertheless a study conducted in Sweden had suggested that such ECG changes are more associated with SAH (15%) than intracranial tumours (13%) . However, there had been recent studies concluding that the ECG changes in neurological diseases are not as frequent as reported in the literature and such changes are “non-specific” .
The presence of an intracranial tumour is an absolute contraindication for administration of fibrinolytic agents such as Streptokinase. Thus misdiagnosis of such ST elevations as STEMI would invariably lead to the decision to anticoagulate with short acting heparin which inturn may culminate intracranial bleeding and resulting deterioration of the neurological condition as in our patient.
We present a female patient with a large intracranial tumour who presented with an ECG mimicking inferior ST elevation MI. The same mechanisms which cause ECG changes in SAH and increased ICP might be responsible for the ECG changes seen in intracranial tumours. This case also emphasises the importance of cardiac biomarkers, 2D ECHO and coronary angiogram in the diagnosis of ACS when faced with diagnostic dilemma. The ECG changes could be misleading in patients with intracranial pathologies. Thus, a more holistic analysis should be practised in diagnosing acute coronary events in such patients to obviate a myriad of unnecessary investigations, interventions, costly treatment strategies.
Acute coronary syndrome
ST elevation myocardial infarction
Erythrocyte sedimentation rate
Glasgow Coma Scale
This case report was supported by ward doctors in acquisition, analysing and interpretation of data. We are thankful to the patient’s relatives for the support given in providing data.
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Availability of data and materials
The datasets supporting the conclusions of this article are included within the article.
Dr. N.Y. and Dr.H.M.M.T.B.H. collected data, followed up the patient and did the literature review and drafted the manuscript. Dr.S.P. and Dr.A.K. corrected the manuscript. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
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