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
TWI Raised intracranial pressure (ICP) SAH

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
ECG SAH Prolonged QTc TWI

Subarachnoid Haemorrhage

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

Example 3
Subarachnoid Haemorrhage ECG

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

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 700

ECG LIBRARY

Electrocardiogram

Emergency physician MA (Oxon) MBChB (Edin) FACEM FFSEM with a 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) 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

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.