Neurogenic T Waves Preceding Acute Ischemic Stroke
A 52-year-old woman presented to the emergency department complaining of atypical chest and epigastric pain. Although her neurological examination was completely normal, her ECG revealed deep, symmetric T-wave inversions in all vascular distributions, consistent with neurogenic T waves (Figure 1). Fifty minutes after the initial ECG, the patient developed left-sided hemiplegia, facial droop, eye deviation, and hemineglect. Immediate non-contrast head computed tomography (CT) revealed a density in the distribution of the right middle cerebral artery (Figure 2). Subsequent angiography confirmed the presence of thrombus at the origin of the right middle cerebral artery (hyperdense middle cerebral artery sign) that persisted despite administration of intravenous and intra-arterial tissue plasminogen activator (Figure 3). Further review of the CT scan showed hypodensity of the right insula, suggesting that this area had been ischemic for longer than the patient had had neurological symptoms. It has been suggested1 that the right insular cortex plays an important role in the development of neurogenic T waves through its autonomic cardiovascular regulation. We suspect that a small thrombus affecting only the right insular cortex was responsible for the patient’s isolated ECG changes and foreshadowed her larger and more devastating acute stroke.