ICH

Intracranial hemorrhage can produce EKG changes that mimic ischemia. There is a large variety of changes that can be seen, mostly postulated from a large sympathetic response and subsequent vasospasm. These changes can be bradyarrhythmias, ST elevation or depression (even mimicking OMI), and U waves. There is a classic T wave inversion pattern ('cerebral T waves') that is commonly discussed. Although most of these findings are from large SAH, intraparenchymal hemorrhage, TBI, or even massive ischemic stroke can also cause these findings.

Cerebral T waves are very large and wide inverted T waves with a prolonged QT. These are typically widespread and not mistaken for other pathology due to their size; however, sometimes the inverted T waves are smaller and can be mistaken for ischemia. Sometimes, the combination of large, inverted T waves with ST elevation is called the 'spiked helmet sign' after the old Prussian war helmets.

Source: Circulation

Examples:

Source: LITFL

Diffuse T wave inversions with massive T waves in the anterolateral leads with ST depression and prolonged QT typical of cerebral T waves.

Source: LITFL

Diffuse T wave inversions with T waves that are large (relative to the QRS complexes) that is also typical for cerebral T waves.

Source: LITFL

Diffuse ST elevation in a young patient with massive TBI and no coronary artery disease that mimics pericarditis or OMI.

Source: Circulation

This demonstrates the spiked helmet sign of an intracerebral septic embolism. Note the sharp R wave followed by ST elevation into the large, inverted T wave with prolonged QT.