Sunday, March 13, 2016

One reason we get ECGs in stroke patients

This patient presented with a sudden right sided weakness and ophthalmoplegia that was resolving upon presentation to the ED.

Here is his ED ECG:
What do you see?

There are anterior Q-waves, and even some ST elevation.  This is suggestive of LV aneurysm.   CT and CT angiogram were normal.   As all symptoms were resolved, no intervention was undertaken.

MRI confirmed small strokes and some atherosclerotic cerebrovascular disease, which could have been the source of the stroke.  

However, because of the ECG findings, an echocardiogram was done which confirmed LV aneurysm and showed:

1. Decreased left ventricular systolic performance moderate to moderately severe
2. Estimated left ventricular ejection fraction of 35%.
3. Regional wall motion abnormality distal anterior wall and apex diastolic distortion with dyskinesis (aneurysm).
4. A 1.2 x 1.3 cm mural thrombus, the source of embolism causing the patient's TIA

LV aneurysm is a common substrate for LV thrombus.  Whenever you see possible LV aneurysm on the ECG, you should suspect an LV thrombus.

The patient was started on heparin and transitioned to coumadin.  He could not recall ever having a myocardial infarction.

Learning Point:

The ECG can be helpful in finding an embolic source of stroke if:

1. There is atrial fibrillation
2. There is evidence of LV Aneurysm, which may harbor a thrombus as source of emboli


  1. Interesting case, which illustrates an ECG that turned out to reflect LV aneurysm despite no more than minimal ST elevation (and ischemic vs reperfusion T waves in V3-V5).

    I’d make a few points about this tracing while raising an additional question. First, the prominent notching in the S wave in V2 in association with no more than minimal ST elevation suggests whatever transpired is not acute. It would be all-too-easy to overlook the fact that there IS an Q wave in lead V3, if one did not look lead-to-lead at how the QRS evolves over the course of the precordial leads. This Q in V3 IS significant — as it just should NOT be there (esp. given lack of lateral chest lead Q waves in V5,V6 which is where “septal” q waves normally lie). Thus there are abnormal Q waves not only in V1,V2 — but also in V3.

    I suspect there may be some lead malposition however, as transition between the QRS picture we see in leads V2-to-V3 is quite abrupt. Nevertheless, prior anterior infarction is likely.

    My question in a patient who presents with new onset stroke symptoms but no chest pain is whether instead of LV aneurysm — this ECG might not have reflected a fairly recent (but not “acute” ) anterior infarction that may have occurred days-to-a-week-or-two earlier? The Echo (and perhaps additional history) helped to sort out the differential in this case and prove LV aneurysm as the source of this ECG picture — but I would think this tracing might be equally representative of a recent infarction stage prior to aneurysm formation …

    Finally, I’ll add the thought that ~ 2% of acute infarctions may present as stroke (a bit more or less as I understand, depending on definitions and site) — so in addition to looking for site of emboli in a patient who presents with stroke but no chest pain — the ECG may help identify the small-but-important percentage of acute stroke patients with acute MI.

  2. Interesting case! Was there any consideration of stress cardiomyopathy in this patient or a follow-up TTE? Though outside the scope of this case, the cause of his cardiomyopathy seems unclear. I think the neuro cases with abnormal ECG can present a bit of a chicken-or-egg question because CNS events like stroke/seizure have also been associated with myonecrosis and stress cardiomyopathy which can be accompanied with aneurysmal ECG changes.

    1. Ali,
      To me, this does not look like Stress Cardiomyopathy. That has much more obvious ST-T abnormalities, longer QT, and absence of Q-waves. It would look much more acute. These all look like chronic findings.
      Steve Smith

  3. Wow, so much information packed into one ECG. This is why I love ECGs, they are often diagnostic if one knows what to look for.

    Would you say that the inverted Wellens'-like T-waves in V3-V5 are indicative of CNS pathology?

    Thanks for the great case.


    1. Dan,
      these are NOT acute findings. Stroke is the result, not the cause of the ECG findings. ST-T changes are much less striking than QRS (Q-wave) findings.

  4. hello doctor, thank you for these infos,
    I have a small question if I want to differentiate between LV aneurysm and anterior MI,
    Is it by the other anterior chest leads (v2/v3)? or there is another way

    1. Zaid,
      anterior LV aneurysm is an anterior MI, but an old one with persistent ST elevation
      Acute STEMI can be differentiated by the size of the T-waves relative to the QRS, specifically T/QRS ratio.
      I have derived and validated a rule. See these posts:
      Steve Smith


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