ECG Changes in Intracranial Hemorrhage

A 78-year-old man was admitted to the hospital with a recent history of severe headache of sudden onset and dense right hemiplegia and altered sensorium. He had a past history of cerebrovascular accident, hypertension, and type 2 diabetes mellitus. He had been a heavy smoker for many years.

A CT scan of the head revealed evidence of intracranial hemorrhage in the left basal ganglia region with shift of the midline. The ECG showed diffuse T wave inversion in the anteroseptal leads (V₁ to V₆). Such T wave inversions are well known to occur with intracranial hemorrhage, and clinicians need to be aware of this ECG finding because in this setting it does not indicate underlying cardiac ischemia.

The patient was treated with labetalol for control of hypertension, but unfortunately he died 2 days after admission.

Hypertension and cerebral amyloid angiopathy cause the majority of intracranial hemorrhages. The most common sites are the basal ganglia (ie, the putamen and the thalamus), the cerebellum, and the pons. The clinical presentation is typically the abrupt onset of a focal neurologic deficit. Hemorrhage in the putamen is associated with deep coma and quadriplegia. Hemorrhage in the cerebellum is associated with occipital headaches and gait ataxia. A CT scan of the head without contrast is diagnostic.

Hypertensive intracerebral hemorrhage has a high mortality rate. The size and location of the hematoma also determine the prognosis. Management should focus on control of the hypertension; at the same time, severe hypotension should be avoided. Evacuation of the hematoma is not helpful except in cerebellar hematoma.