P070: BRAIN OR HEART?
Benjamin Segil, DO, Jeffrey Huang, MD, FASA; HCA GME Oak Hill Hospital
Introduction/Background: A 69 year old male presented to the emergency department with left sided weakness, left hemifacial paralysis, and dysarthria. This patient was found to be suffering from an acute right middle cerebral artery ischemic stroke based on CT imaging. The patient presented six hours after his last known normal time, and determined not to be a candidate for systemic tissue plasminogen activator (tPA) therapy. Interventional radiology reviewed the images and determined the lesions would be amenable to mechanical thrombectomy and revascularization. As part of the patient’s evaluation in the emergency department an electrocardiogram (ECG) demonstrated ST segment depression in precordial leads V2-V6, with T wave inversion in V1 and V2. These changes were noted to be increased on repeat ECG three hours later. The patient never complained of chest pain, and did not report any cardiac history, however home medications included dabigatran. The patient’s family consented to proceeded with the cerebral angiography with mechanical thrombectomy.
Methods: Standard ASA monitors were applied, and the patient was induced for general anesthesia with endotracheal intubation using fentanyl, propofol, and rocuronium. Anesthesia was maintained with sevoflurane, and a phenylephrine drip was utilized for blood pressure support. The proceduralist obtained femoral arterial access and performed cerebral angiography, intra-arterial mechanical thrombectomy, emergent right carotid angioplasty and stenting with attempted distal protection.
Results: Intraoperatively, a cardiologist was consulted to determine if concurrent coronary angiography was necessary at this time. The cardiologist decided to delay coronary angiography until the patient had recovered from the acute phase of the stroke. Troponin I levels were trended post operatively and peaked at 5.34. The cardiology team obtained an echocardiogram, with revealed no wall motion abnormalities and a normal ejection fraction. Cardiology followed the patient through his hospital course, and deferred angiography for an elective procedure. The patient was discharged on hospital day six to acute rehab, with continued altered mental status and left sided deficits.
Discussion/Conclusion: It is important for an anesthesia provider to remember when evaluating a patient for anesthesia that ECG changes and elevated troponins levels do not always indicate an acute myocardial infarction. Classically described large upright T waves may appear in the presence of a CVA, but may also present with T wave inversions, similarly to patients with intracranial hemorrhages. There are often nonspecific ST segment changes seen in patients with a stroke, more commonly in the lateral leads, as well as aberrant Q waves. The abnormal ECG findings are thought to be from a neurogenic cause. Additionally, elevated troponin levels after a CVA’s may be a poor prognostic sign.
A cautious approach to treatment of concurrent disease states must be applied, as systemic anticoagulation and antiplatelet therapy is indicated for one condition, but contraindicated for the other. It is important for the medical team to make a balanced decision when caring for a patient in this situation.