• Images in cardiology

A 60 year woman presented with recurrent syncope and frequent episodes of self terminating polymorphic ventricular tachycardia. She had a previous history of mechanical valve replacement for rheumatic mitral valve disease and atrioventricular node ablation and pacemaker implantation for atrial fibrillation. Her 12 lead ECG demonstrated a ventricular paced rhythm but profound prolongation of QT interval (QTc = 694 ms). An ECG performed two years previously had demonstrated her QT interval to be within normal limits. Her arrhythmias resolved with reprogramming of her pacemaker to a faster ventricular rate.

Soon after admission she became paraplegic with a sensory level to T10. Subsequent myelography and computed tomographic imaging demonstrated frank blood in the cerebrospinal fluid and an extradural haematoma at the level of T4 with complete blockage of contrast flow. This was managed conservatively with reversal of her anticoagulation. She made a limited neurological recovery. Her ECG returned to normal.

Interpretation of repolarisation changes on the surface ECG in a paced rhythm is difficult. However, in this case normal repolarisation had been demonstrated before and after the patient’s arrhythmic event. Gross abnormalities of repolarisation with polymorphic ventricular tachycardia have previously been reported in patients with subarachnoid haemorrhage. It is feasible that this patient had extension of her epidural haematoma to the subarachnoid space precipitating her arrhythmias.