Cardiopulmonary complications in acute subarachnoid hemorrhage

Pathologic electrocardiogram (ECG) may be present in more than 90% of patients with subarachnoid haemorrhage. The ECG findings are often transient and may mimic acute myocardial ischaemia or infarction. These ECG findings may cause diagnostic problems in patients with subarachnoid haemorrhage who are unconscious or who have atypical symptoms. Life-threatening arrhythmias are also seen and may be responsible for sudden deaths in patients with subarachnoid haemorrhage. Other signs of myocardial injury, such as ventricular wall motion dysfunction, elevated enzymes, and histological evidence of contraction band necrosis are described. The myocardial dysfunction known as neurogenic stunned myocardium is reversible if the patient survives the acute phase, but it may lead to haemodynamic instability and contribute to the origin of neurogenic pulmonary oedema. The myocardial injury in subarachnoid haemorrhage may be due to a massive sympathetic stimulation of the myocardium in response to rapidly increasing intracranial pressure. We illustrate myocardial injury and dysfunction in a case report where a patient had subarachnoid haemorrhage with ventricular fibrillation, pulmonary oedema, left ventricular dysfunction and ST-segment elevation, initially thought to be acute myocardial infarction.