Catherine Albin, MD
Neurocritical Care Faculty
Emory University, United States
Disclosure information not submitted.
Title: A New Basal Ganglia Infarct with Unstable Bradycardia
Case Report Body:
Introduction: Significant brain injuries such as high grade subarachnoid hemorrhage, large ischemic strokes, and severe traumatic brain injury have long been known to cause cardiac complications described as the brain-heart connection. We present the unusual case of a small basal ganglia ischemic insult causing diffuse T-wave inversions and bradycardic arrest.
Description: 74-year-old woman with past medical history of hypertension and diabetes mellitus presented to the emergency room after awakening with right sided weakness that progressed to facial droop and slurred speech later that evening. Non-contrast head CT and CTA head were without significant pathology. Initial NIH score was 11. Presenting vitals were significant for hypertension and marked sinus bradycardia. Admission ECG demonstrated a new right bundle branch block and normal troponins. Abruptly overnight she suffered worsening bradycardia and ultimately had a cardiac arrest requiring epinephrine for return of spontaneous circulation. ECG revealed diffuse, deep T waves throughout all leads; troponins were negative and ECHO did not demonstrate wall motion abnormalities or Takatsubo pattern. MRI completed the next demonstrated a subacute infarct abutting the left insula within the corona radiata and posterior limb of internal capsule.
Discussion: Cardiac abnormalities such as arrhythmias, QTc prolongation, and stunned myocardium may be present in up to 20% of patients after an ischemic stroke, often early in the post-stroke period. A complex and incompletely understood mechanism underpins these changes and may include hypothalamic–pituitary–adrenal axis signaling, catecholamine surge from sympathetic and parasympathetic dysregulation, and/or a systemic inflammatory response. “Cerebral T waves” – deep T wave inversions throughout all leads have been reported in 2-18% of patients after ischemic injury. However, they are almost always found in patients with either large ischemic burdens, insular or brainstem ischemia. Our case demonstrates that these complications may infrequently arise in patients with small ischemic strokes near the autonomic cerebral centers. It is therefore essential to utilize ECG monitoring and to have a high clinical suspicion for these arrhythmic complications in post-stroke patients.