Abstract
Objective: We report a lifethreatening and preventable complication of Subarachnoid hemorrhage seen in combination with prolong Q-T interval and use of Phenyleprine resulting in Torsades de pointes.
Background: Torsades de pointes (TdP) is a ventricular tachycardia that rotates around a horizontal axis, occuring in the setting of a prolonged QT interval. Cardiac complications following aneurysmal subarachnoid hemorrhage (SAH) are quite common. These include myocardial injury, electrocardiogram (ECG) changes and stress induced cardiomyopathy. ECG changes typically include QT prolongation, ST segment elevation and inverted T waves. The pathophysiology of these changes is due to a sudden catecholamine release in response to the acute hemorrhage. Torsades de pointes has been reported in a handful of times and always in the context of the acute hemorrhage-within the first 48 hours and during a peri-operative state for aneurysm clipping.
Design/Methods: We report a patient with prolonged QT interval following rupture of a cerebral aneurysm causing subarachnoid hemorrhage who developed multiple episodes of TdP on day 9. She was initially converted back to sinus rhythm by direct cardioversion. Temporary pacemaker was followed by a permanent to allow for over-pacing. She made full recovery. Follow-up ECG 3 months after discharge showed that her QT interval had returned to normal. The cause of her malignant rhythm was due to combination of bradycardia as a side effect of phenylephrine and prolonged QT interval.
Results: This reports points to a serious complication from combination of prolong Q-T interval and phenylephrine which can occur late and treatable and can be avoidable.
Conclusions: Phenylephrine is commonly used after SAH to induce hypertension as a treatment of vasospasm. The combination of phenylephrine induced bradycardia and SAH induced QT prolongation can have dangerous consequences. Neurointensivists should be aware of this potential complication and also be familiar with TdP and how to treat it.
Disclosure: Dr. Ahmed has nothing to disclose. Dr. Boland has nothing to disclose. Dr. Carpenter has nothing to disclose.
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