Spiked Helmet Sign

A few years ago Littmann et al. described a new electrocardiographic sign characterized by a dome-and-spike patterned apparent ST segment elevation, where the upward shift of the baseline started beforeand ended after the QRS complex.

It was named “Spiked Helmet” sign because of the resemblance to the “Pickelhaube”, a German military spiked helmet introduced in 1842 by Friedrich Wilhelm IV, the King of Prussia. This ECG sign was observed in a number of hospitalized critically ill patients that had ST segment elevation in their ECG but didn’t have STEMI. The presence of this ECG pattern was associated with critical illness and very high risk of in-hospital death.

Image reproduced from Agarwal A, Janz T, Garikipati N. Spiked helmet sign: An under-recognized electrocardiogram finding in critically ill patients. Indian Journal of Critical Care Medicine 2014;18(4):238.

In the original article and in subsequent publications, numerous cases were presented with this ECG pattern and with myocardial infarction ruled out. Acute abdominal events such as ileus, bowel perforation, gastric obstruction were associated with spiked helmet pattern in the inferior leads whereas acute thoracic events such as aortic dissection, pneumothorax and mechanical ventilation were associated with spiked helmet pattern in the chest leads.

The exact mechanism of this electrocardiographic sign remains uncertain. The observations of Littmann et al. and Tomcsányi et al. suggest that the pseudo-ST elevation is probably due to repetitive epidermal stretch that occurs in concert with the cardiac cycle due to an acute rise in intrathoracic or intraabdominal pressure.

References:
1. Littmann L, Monroe MH. Tombstone ST elevation without myocardial infarction: A variant of the “Spiked Helmet” sign? The American Journal of Medicine 2013;126(8):e9–10.
2. Littmann L, Monroe MH. The “Spiked Helmet” sign: A new Electrocardiographic marker of critical illness and high risk of death. Mayo Clinic Proceedings 2011;86(12):1245–6.
3. Agarwal A, Janz T, Garikipati N. Spiked helmet sign: An under-recognized electrocardiogram finding in critically ill patients. Indian Journal of Critical Care Medicine 2014;18(4):238.
4. Hibbs J, Orlandi Q, Olivari MT, Dickey W, Sharkey SW. Giant J waves and sT-segment elevation associated with acute gastric distension. Circulation 2016;133(11):1132–4.
5. Littmann L. Letter by Littmann regarding article, “Giant J waves and sT-segment elevation associated with acute gastric Distension.” Circulation 2016;134(8):e109–10.
6. Littmann L, Proctor P. Real time recognition of the electrocardiographic “spiked helmet” sign in a critically ill patient with pneumothorax. International Journal of Cardiology 2014;173(3):e51–2.
7. Tomcsányi J, Frész T, Proctor P, Littmann L. Emergence and resolution of the electrocardiographic spiked helmet sign in acute noncardiac conditions. The American Journal of Emergency Medicine 2015;33(1):127.e5–127.e7.

 

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