Not all T wave inversions are ischaemic.

To cite: Rajendran R, Patel JS, Singla V, et al. BMJ Case Reports Published online: [please include Day Month Year] doi:10.1136/ bcr-2012-008219 DESCRIPTION A 52year-old man was referred as a case of acute coronary syndrome (ACS) for he had chest pain, vomiting and deep T wave inversions on ECG. Physical examination was normal except for blood pressure of 190/100 mm Hg. ECG (figure 1) satisfied voltage criteria for left ventricular hypertrophy along with deep asymmetrical T wave inversions, a prominent U wave and a prolonged corrected QT interval (QTc 560 ms). Echocardiogram confirmed concentric left ventricular hypertrophy but there was no regional wall motion abnormality, serum potassium was low (2.5 mEq/l) and cardiac biomarkers were normal. Considering accelerated hypertension he was treated with oral amlodipine and intravenous nitroglycerine. Before resorting to ACS treatment, in view of headache, vomiting and significantly prolonged corrected QT interval along with deep T wave inversions, an intracranial bleed was considered. Subsequently, this was confirmed by a CTof the brain, which showed a haemorrhage involving the left temporo-parietal region (figure 2). Interestingly, there was no focal neurological deficit till 6 h after presentation. After treating the patient with intravenous mannitol the T inversions normalised and the corrected QT also improved to 496 ms (figure 3). Deep T wave inversions although commonly because of ischaemia and left ventricular hypertrophy(LVH), a neurogenic T wave has to be suspected when the QTc is significantly prolonged. 1