ST-Segment Elevation in a Young Woman with a Brain Bleed

A 23 yo woman with a history of traumatic brain injury was re-admitted to the hospital two months after initial hospitalization for a traumatic head injury. Readmission was prompted by follow-up computed tomography head scan that revealed hydrocephalus and a shrunken brain for which she underwent cranioplasty and a ventriculoperitoneal shunt. On post-operative day one, she developed “tombstone” ST-segment elevations (STE) which cleared spontaneously without therapeutic intervention. Echocardiography was normal and troponin was minimally elevated. Head CT revealed an epidural hematoma with midline shift, to which the striking ECG changes were attributed. The hematoma was evacuated and the patient was discharged to her care facility. She was readmitted several times during the ensuing eight-months for recurrent hydrocephalus with external ventricular drain placement. During these episodes, there was no evidence of recurrent STE. Although multiple ECG alterations have been described in association with cerebral injury, tombstone STE is rare in this setting.