Is it the Heart or the Brain?

Case Report

Austin J Clin Case Rep. 2014;1(6): 1029.

Is it the Heart or the Brain?

Dashora Umesh1, Al-Abdullah Alhasan2* and Joarder Rita3

1Department of Medicine, Conquest Hospital, UK

2Department of Oncology, Guy’s Hospital, UK

3Department of Radiology Conquest Hospital, UK

*Corresponding author: Al-Abdullah Alhasan, Department of Oncology, Guy’s Hospital, UK

Received: June 28, 2014; Accepted: July 20, 2014; Published: July 24, 2014


A 66 year old gentleman was brought to the Accident and Emergency department after he was found unconscious in the toilet. He had new ECG changes. An urgent CT scan showed no haemorrhage, infarction or space-occupying lesion. The patient was initially treated as a case of acute coronary syndrome. The troponin level 12 hours after the episode was normal. Consciousness gradually improved and further neurological examination revealed gait ataxia with right sided deviation. MRI scan of the brain showed a large acute cerebellar infarct. The patient improved with the standard treatment regimen for stroke and made a good recovery.

Keywords: ECG changes in acute stroke; Heart; Brain


ECG: Electrocardiography; CT: Computerised Tomography; MRI: Magnetic Resonance Imaging; GCS: Glasgow Coma Scale; CRP: C - reactive protein; PICA: Posterior Inferior Cerebellar Artery; ACS: Acute Coronary Syndrome; INR: International Normalized Ratio

Case Presentation

A 66 year old gentleman presented with his partner to the Accident and Emergency department after he had been found unconscious in the toilet. According to his partner, he had complained of a headache, nausea and vomiting for two days. There were no such episodes in the past. There was a past history of myocardial infarction, pericarditis, and paroxysmal atrial fibrillation on warfarin treatment, hypertension and peripheral vascular disease. He had stopped all his medications 15 days before this episode. On examination, he was pale and drowsy with a Glasgow Coma Scale score of 7/15 on initial review by paramedical staff. Consciousness gradually improved with GCS score rising to 11/15 by the time he arrived to the hospital. Pulse was 63 per minute irregular and BP 176/86 mm of Hg. Chest, heart and abdominal examinations were unremarkable. Initial neurological examination revealed no nystagmus, normal eye movements, no facial droop, normal reflexes and tone. The patient’s GCS improved to 15/15 within 12 hours. He denied any chest pain in relation to this episode. More detailed neurological examination was possible after 12 hours and revealed gait ataxia with right sided deviation. Interestingly, there was no dysarthria, dysphagia, limb ataxia, dysmetria, past-pointing, dysdiadochokinesis or rebound phenomenon; nor could we find any positive signs of brain stem dysfunction including Horner’s syndrome, dissociated sensory loss, pathological head-impulse test or paresis of the soft palate.


Blood tests showed normal blood counts, renal function and CRP. High sensitivity troponin on admission was 11ng/l with no change after 6 hours. The INR was 1.0.

An ECG on admission showed flutter fibrillation, ST segment flattening in leads v1-v3 with T wave inversion in multiple leads (changes were new and dynamic compared to previous ECGs) (Figure1). In view of the altered consciousness level and sub-therapeutic INR, an urgent CT brain was performed on admission which showed no acute infarction or bleed and no space-occupying lesion. When ataxia was noted on the second day, an urgent MRI scan of the brain was requested. The scan could only be performed 5 days after admission and showed a large acute right sided ischaemic infarction with marked associated oedema, midline shift of cerebellum and distortion of the brainstem and fourth ventricle (Figure 2).

Citation: Umesh D, Al-Abdullah Alhasan and Rita J. Is it the Heart or the Brain?. Austin J Clin Case Rep. 2014;1(6): 1029. ISSN 2381-912X