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STEMI in a Patient With Recent Intracranial Hemorrhage
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A 63-year-old male patient with a history of hypertension presented to the emergency department with a one-day history of dizziness, nausea, and vomiting. A computed tomography (CT) scan of the brain demonstrated the presence of an acute intracranial hemorrhage in the cerebellar vermis, which was urgently treated with coil embolization. He was thereafter admitted with plans for a sub-occipital craniotomy. During induction he became hypotensive, requiring vasoactive medications including epinephrine, phenylephrine, and ephedrine. Shortly after, ST segment elevations were noted on the telemetry monitor. This was followed by an electrocardiogram, which demonstrated ST segment elevation in the inferior leads with reciprocal changes (Figure).
After a multi-disciplinary discussion, the patient was urgently transferred for another head CT to ensure no further bleeding was noted and then to the catheterization lab where he underwent a coronary angiogram via the femoral artery. The femoral artery was utilized so as not to use heparin and for possible placement of an intra-aortic balloon pump if needed. The procedure demonstrated significant coronary vasospasm responsive to intra-coronary nitroglycerin (Videos 1 and 2). The patient was treated with calcium channel blockers and had an uneventful hospital course; his surgery was postponed to the outpatient setting.
Coronary artery vasospasm is a relatively rare but well-established cause of myocardial ischemia. Known triggers include blood flow redistribution, an exaggerated catecholamine response, or administration of adrenergic agonists. Our case in particular highlights the challenging clinical decision-making needed by our multi-disciplinary team when treating a patient with recent intracranial hemorrhage.
Affiliations and Disclosures
From the 1Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan, USA; 2Department of Cardiology, Henry Ford Hospital, Detroit, Michigan, USA.
Disclosures: Dr Basir is a consultant for Abiomed, Boston Scientific, Chiesi, Saranas, and Zoll. The remaining authors report no financial relationships or conflicts of interest regarding the content herein.
Address for correspondence: Mohamed Maki, MBBCh, 2799 W. Grand Blvd, Detroit, MI 48202, USA. Email: Mmaki4@hfhs.org
