ECG Case 012

Main Abnormalities

• Giant T-wave inversions in multiple leads, most prominent in V2-6
• Marked QT prolongation > 600 ms

Diagnosis

This ECG pattern is characteristic of raised intracranial pressure and is classically seen in the context of massive intracranial haemorrhage, particularly:

• Aneurysmal subarachnoid haemorrhage
• Haemorrhagic stroke

Similar ECG patterns have also been reported in patients with raised ICP due to:

• Large-territory ischaemic stroke causing cerebral oedema (e.g. MCA occlusion)
• Traumatic brain injury

The differential diagnosis for widespread T-wave inversions and QT prolongation includes myocardial ischaemia (e.g. Wellens syndrome) and electrolyte abnormalities (e.g. hypokalemia). However, neither condition would cause the gigantic “cerebral T waves” seen here.

Further Reading

• Wiesbauer F, Kühn P. ECG Mastery: Yellow Belt online course. Understand ECG basics. Medmastery
• Wiesbauer F, Kühn P. ECG Mastery: Blue Belt online course: Become an ECG expert. Medmastery
• Kühn P, Houghton A. ECG Mastery: Black Belt Workshop. Advanced ECG interpretation. Medmastery
• Rawshani A. Clinical ECG Interpretation ECG Waves
• Smith SW. Dr Smith’s ECG blog.
• Wiesbauer F. Little Black Book of ECG Secrets. Medmastery PDF