Raised Intracranial Pressure

Characteristic ECG Abnormalities with Raised Intracranial Pressure

Other possible ECG changes that may be seen:

  • ST segment elevation / depression — this may mimic myocardial ischaemia or pericarditis
  • Increased U wave amplitude
  • Other rhythm disturbances: sinus tachycardia, junctional rhythms, premature ventricular contractions, atrial fibrillation

In some cases, these ECG abnormalities may be associated with echocardiographic evidence of regional ventricular wall motion abnormality (so-called “neurogenic stunned myocardium”).


Causes

ECG changes due to raised ICP are most commonly seen with massive intracranial haemorrhage:

  • Subarachnoid haemorrhage
  • Intraparenchymal haemorrhage (haemorrhagic stroke)

They may also be seen with:

  • Massive ischaemic stroke causing cerebral oedema (e.g. MCA occlusion)
  • Traumatic brain injury
  • Cerebral metastases (rarely)

In one case series, the ECG pattern of cerebral T-waves with prolonged QT interval was seen in 72% of patients with SAH and 57% of patients with intraparenchymal haemorrhage. 


ECG Examples
Example 1

Subarachnoid Haemorrhage

  • Widespread, giant T-wave inversions (“cerebral T waves”) secondary to subarachnoid haemorrhage
  • The QT interval is also grossly prolonged (600 ms)

Example 2

Subarachnoid Haemorrhage

  • Another example of cerebral T-waves with marked QT prolongation secondary to subarachnoid haemorrhage

Example 3

Subarachnoid Haemorrhage

  • Widespread T-wave inversions with slight ST depression secondary to subarachnoid haemorrhage
  • The QT interval is prolonged (greater than half the R-R interval)
  • This ECG pattern could easily be mistaken for myocardial ischaemia as the T-wave morphology is very similar, although obviously the clinical picture would be very different (coma versus chest pain)

Example 4

Traumatic Brain Injury

  • This ECG was taken from a previously healthy 18-year old girl with severe traumatic brain injury and massively raised intracranial pressure (30-40 mmHg)
  • There is widespread ST elevation with a pericarditis-like morphology and no reciprocal change (except in aVR and V1)
  • She had no cardiac injury / abnormality to explain the ST elevation
  • The ST segments normalised as the intracranial pressure came under control (following treatment with thiopentone and hypertonic saline)


References

  • Jachuck, SJ. Electrocardiographic abnormalities associated with raised intracranial pressure. Br Med J. 1975 Feb 1; 1(5952): 242–244. PMC 1672050
  • Gregory, T. Cardiovascular complications of brain injury. Contin Educ Anaesth Crit Care Pain (2012) 12 (2): 67-71. doi: 10.1093/bjaceaccp/mkr058

Advanced Reading

Online

Textbooks


LITFL Further Reading

ECG LIBRARY

Electrocardiogram

Associate Professor Curtin Medical School, Curtin University. Emergency physician MA (Oxon) MBChB (Edin) FACEM FFSEM Sir Charles Gairdner Hospital.  Passion for rugby; medical history; medical education; and asynchronous learning #FOAMed evangelist. Co-founder and CTO of Life in the Fast lane | Eponyms | Books | Twitter |

MBBS (UWA) CCPU (RCE, Biliary, DVT, E-FAST, AAA) Adult/Paediatric Emergency Medicine Advanced Trainee in Melbourne, Australia. Special interests in diagnostic and procedural ultrasound, medical education, and ECG interpretation. Editor-in-chief of the LITFL ECG Library. Twitter: @rob_buttner

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