SFGH 3.7 am report pearls: ECG changes in intracranial hemorrhage and Takatsubo

EKG changes with intracranial hemorrhage:

  • ECG changes are frequent in patients with ischemic stroke, subarachnoid hemorrhage (27%-100%) and intracerebral hemorrhage (56%)
  • theories for mechanism of ECG changes include hypothalamic stimulation and autonomic dysregulation including excess of catecholamines that can damage myocytes directly or lead to generalized spasm of the coronary
  • common EKG changes: high R waves, ST depression, T wave abnormalities, large U waves, prolonged QTc


Takatsubo cardiomyopathy: (from prior SFGH Pearls)


  • From the Japanese, “tako-tsubo” meaning “fishing pot for trapping octopus”,– (based on similarity to the shape of the LV in the typical form)
  • More common in elderly or postmenopausal women (80-100 percent of cases)
  • Frequently with onset after acute emotional stress or an acute medical condition
  • More often mimics acute MI with substernal chest pain, dyspnea, shock; although case reports of syncope as the presenting symptom are reported
  • rule out pheochromocytoma, myocarditis, ACS, intracranial or subarachnoid bleeding
  • ST elevations in 30-50%, often troponin elevations
  • Echo with apical ballooning in 50-66%, apical sparing in atypical cases
  • Complications: heart failure, tachyarrhythmias, MR, shock
  • Treatment: no controlled data, reasonable to treat for LV dysfunction with ACE-I, beta blockers, and diuretics prn
  • Recovery often occurs in 1-4 weeks

Bybee KA, Kara T, Prasad A, et al. Systematic review: transient LV apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction. Ann Internal Medicine 2004

Takeuchi et al. Electrocardiograph abnormalities in intracerebral hemorrhage.  Journal of Clinical Neuroscience.  22(12) 1959-1962.

Bailey WB, Chaitman BR. Electrocardiographic changes in intracranial hemorrhage mimicking  myocardial infarction. N Engl J Med 2003;349:561-561


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