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A 58 year old man was admitted to his local emergency department in electromechanical dissociation (EMD), having collapsed at home. Cardiac output soon returned
following an adrenaline bolus. His pupils were normal size and reacting, there was no neck stiffness, and he moved his right leg spontaneously. A diagnosis of acute anterior myocardial infarction with EMD arrest was made with ECG evidence of extensive 3–4 mm ST elevation in leads V1–V3, lateral ST depression, and inferior T wave inversion (top left). He was sedated and paralysed and transferred to a nearby tertiary centre for primary angioplasty rather than thrombolysis in view of a large groin haematoma and recent arrest. Coronary angiography, however, was entirely normal, despite persistent ECG abnormalities. Ventriculography showed a mildly hypokinetic anterior wall. A computed tomographic (CT) scan of the patient's head was arranged to look for an alternative diagnosis. This showed evidence of an extensive subarachnoid haemorrhage with blood throughout the ventricular system and basal cisterns (bottom left). Despite inotropic support, he gradually deteriorated and died 16 hours after admission.
ECG abnormalities occur commonly in subarachnoid haemorrhage, probably caused by subendocardial ischaemia following excessive noradrenaline (norepinephrine) release. Echocardiography is often unhelpful in ruling out an acute coronary syndrome, because of a high prevalence of associated regional wall motion abnormalities in the territory of the ECG changes, as in this case. Patients who present to hospital with ECG evidence of acute myocardial infarction but reduced level of consciousness should undergo an urgent CT head scan to rule out subarachnoid haemorrhage, certainly before thrombolysis is considered.