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Year : 2020  |  Volume : 7  |  Issue : 5  |  Page : 285-287

Giant asymmetrically peaked T-waves in a child with raised intracranial pressure due to acute central nervous system infection: A case report and review of the literature

Department of Pediatrics, Division of Pediatric Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Date of Submission26-May-2020
Date of Decision15-Jun-2020
Date of Acceptance27-Jun-2020
Date of Web Publication14-Sep-2020

Correspondence Address:
Dr. Ramachandran Rameshkumar
Department of Pediatrics, Division of Pediatric Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry - 605 006
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JPCC.JPCC_91_20

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Although various changes in electrocardiogram (ECG) were reported with normal serum potassium levels in acute intracranial pathology, giant asymmetrical T-wave change has not been reported. We report a case of a previously healthy male child who presented with acute febrile illness and features of raised intracranial pressure. Full standardized ECG shows normal sinus rhythm and tall, broad, and giant asymmetrically peaked T-wave. Serum potassium, echocardiography, and cardiac injury marker were normal. The child managed with supportive care and antimicrobials and showed recovery in 7 days.

Keywords: Central nervous system infections, children, ECG changes, raised intracranial pressure

How to cite this article:
Jain P, Rameshkumar R, Satheesh P, Pavani C. Giant asymmetrically peaked T-waves in a child with raised intracranial pressure due to acute central nervous system infection: A case report and review of the literature. J Pediatr Crit Care 2020;7:285-7

How to cite this URL:
Jain P, Rameshkumar R, Satheesh P, Pavani C. Giant asymmetrically peaked T-waves in a child with raised intracranial pressure due to acute central nervous system infection: A case report and review of the literature. J Pediatr Crit Care [serial online] 2020 [cited 2021 Mar 4];7:285-7. Available from: http://www.jpcc.org.in/text.asp?2020/7/5/285/295028

  Introduction Top

An electrocardiogram (ECG) is one of the most valuable diagnostic tools that record the heart's electrical activity as waveforms. By interpreting these waveforms accurately, we can identify rhythm disturbances, conduction abnormalities, and electrolyte imbalances. ECG changes have also been reported in many noncardiac illnesses.[1] Awareness of characteristic ECG changes in cardiac and noncardiac illnesses such as raised intracranial pressure (ICP) may alert the treating physician for early recognition and timely life-saving interventions. The various ECG changes have been described in a myriad of central nervous system (CNS) lesions. These changes include bradycardia, extrasystoles, abnormal ST-T deflection, prominent U-waves, prolonged QT intervals, and tall, deeply inverted, large upright, or notched T-waves.[2]

  Case Report Top

We describe a case of an 8-year-old developmentally normal male child who presented with complaints of fever for 4 days, altered sensorium for 1 day, four episodes of vomiting, and one episode of a generalized tonic–clonic seizure. On examination, the child was hemodynamically stable with unremarkable system examination except for the low modified Glasgow coma scale (9/15) and upper motor neuron signs. A provisional diagnosis of acute meningoencephalitis was considered and was managed with antiraised ICP measures and empirical antiviral therapy.

Full standardized ECG [Figure 1] showed sinus rhythm, normal axis, heart rate of 60/min, and normal QRS complex duration and PR and QT intervals. However, T-wave abnormalities in this ECG were detected. T-waves were tall, broad, and asymmetrically peaked. T-waves were inverted in V1, V2, avR, and bifid in V3 (marked with an arrow), whereas large upright T-wave was noticed in V4, V5, and V6. The largest amplitude was seen in V4 – 1.8 mV (marked with a small arrow) with a T/QRS ratio of 1.28 which qualifies for giant T-wave. This tall T-wave cannot be explained by hyperkalemia which is a common cause of tall T-wave in our clinical practice as serum potassium level was within the normal range (serum potassium: 4.4 mEq per dL) and normal troponin I. Echocardiography examination was also normal. T-wave abnormality disappeared once the CNS pathology resolved. ECG was normal at discharge. The child was discharged after 7 days of hospital stay with the normal neurological state.
Figure 1: Full standardized ECG shows giant asymmetrically peaked T-waves

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  Discussion Top

The observed ECG findings in the index case were correlated with the ECG findings described in the literature in association with neurologic diseases except for giant asymmetrical T-wave. Tall upright peaked T-waves may be seen in hyperkalemia or myocardial ischemia besides as a normal variant. In 1947, Byer et al. reported large, upright T-waves in patients with arterial hypertension and symptoms and signs of encephalopathy, together with prolongation of the QT interval.[3]

Burch et al. in 1968 reported that prominent upright T-waves are frequently associated with prominent U-waves, prolonged QT interval, and T–U fusion as ECG manifestation of intracranial diseases.[4] In their study, 55 patients with ECG changes thought to be secondary to intracranial lesions, the more typical ECG findings of prolonged QT interval, and large T-wave inversion were seen in only 17 (31%) of the 55 patients, whereas 38 (69%) had the type of upright T-waves.

In a case series of seven patients with varying intracranial conditions and with no evidence of cardiovascular disease, Jachuck et al. studied electrocardiographic abnormalities associated with raised ICP.[2] It was observed that two patients with normal ICP showed no ECG abnormalities, whereas the remaining five patients had different ECG changes. All five patients had T-wave abnormality. T-waves were flat in three patients, notched in one patient, and tall in the other. ECG changes were studied objectively with ICP changes, and it was suggested that tall T-waves are an early ECG manifestation of rising ICP.

As the ICP increases, the tall T-waves became flat and reverted to normal as the ICP with normal ICP. The T-waves became progressively inverted if ICP rises significantly. These T-wave changes were usually seen in the standard leads II, III, aVL, and aVF. Other ECG changes noticed were progressive ST depression with increasing ICP and prominent U-waves. These findings not only confirm the association between ECG abnormalities and CNS diseases but also suggest that many of the ECG abnormalities are related to changing ICP. In addition, it has to be kept in mind that elevated T-waves in ECG can be seen as normal variation in young patients and athletes. Even some medications are also associated indirectly with T-wave abnormalities such as antiarrhythmic, digoxin, and diuretics.[5]

In a study of 161 patients with neurologic diseases by Póvoa et al., the most frequent abnormality observed was ventricular repolarization (23.7%). The presence of T-waves (4.6%) and prolonged QT intervals (8.8%) was the most characteristic of brain injuries.[6] The peculiarity of the index case is the asymmetrically peaked giant T-waves which are different from the ECGs described in other studies.

The exact pathophysiology of this condition remains unclear. Several different mechanisms have been proposed such as the involvement of the neurohormonal system, increased catecholamine levels, and sympathetic outflow. Excess of catecholamines in association with enhanced adrenal production and activation of the calcium channels leads to an increase in calcium levels in cytosolic and mitochondria, as well as the release of free radicals, causing contraction band necrosis and ECG alterations.[6]

Byer et al. reported that large, upright T-waves in the human electrocardiogram, together with prolongation of the QT interval, may often be due to the predominant involvement of ischemic changes in the endocardial surface of the left ventricle muscle layers.[3] A clinically significant prevalence of myocardial injury in patients with acute neurologic illness has been demonstrated by Dixit et al.[7] and confirmed by the finding of the elevated cardiac troponin I level. Kono et al. also reported that patients with subarachnoid hemorrhage and ST-segment elevation may demonstrate transient corresponding regional wall motion abnormalities.[8] T-wave changes in the index patient can also be explained by autonomic disturbances caused by raised ICP.

This report highlights the importance of ECG in noncardiac illnesses, including alterations of the CNS, and should be considered in the diagnosis of diseases resulting in ECG changes, especially when the clinical history does not suggest cardiac disease.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the parents have given their consent for their child's images and other clinical information to be reported in the journal. The parents understand that their child's name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.


We acknowledge the parents of the index patient for giving the consent for publication of their child data in a medical journal and the contribution of Mrs. S. Raja Deepa B. Com, MCA (JIPMER Campus, Puducherry, India), for grammar correction/manuscript review.

Financial support and sponsorship

This study was financially supported, in part, by the institutional and departmental fund.

Conflicts of interest

There are no conflicts of interest.

  References Top

Van Mieghem C, Sabbe M, Knockaert D. The clinical value of the ECG in noncardiac conditions. Chest 2004;125:1561-76.  Back to cited text no. 1
Jachuck SJ, Ramani PS, Clark F, Kalbag RM. Electrocardiographic abnormalities associated with raised intracranial pressure. Br Med J 1975;1:242-4.  Back to cited text no. 2
Byer E, Ashman R, Toth LA. Electrocardiograms with large, upright T waves and long Q-T intervals. Am Heart J 1947;33:796-806.6.  Back to cited text no. 3
Burch GE, Phillips JH. The large upright T wave as an electrocardiographic manifestation of intracranial disease. South Med J 1968;61:331-6.  Back to cited text no. 4
Kenny BJ, Brown KN. ECG T Wave. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2020. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538264/. [Last acessed on 2019 Nov 14].  Back to cited text no. 5
Póvoa R, Cavichio L, De Almeida AL, Viotti D, Ferreira C, Galvão L, et al. Electrocardiographic abnormalities in neurological diseases. Arq Bras Cardiol 2003;80:351-8.  Back to cited text no. 6
Dixit S, Castle M, Velu RP, Swisher L, Hodge C, Jaffe AS. Cardiac involvement in patients with acute neurologic disease: confirmation with cardiac troponin I. Arch Intern Med 2000;160:3153-8.  Back to cited text no. 7
Kono T, Morita H, Kuroiwa T, Onaka H, Takatsuka H, Fujiwara A. Left ventricular wall motion abnormalities in patients with subarachnoid hemorrhage: Neurogenic stunned myocardium. J Am Coll Cardiol 1994;24:636-40.  Back to cited text no. 8


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