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A confusing mimicker of ST-segment elevation myocardial infarction: spiked helmet sign

A 60-year-old man with metastatic lung cancer presented to the emergency department with severe respiratory distress. He was intubated and admitted to e intensive care unit (ICU). Electrocardiography taken at emerge revealed ST-segment elevation in the anterior chest leads compatible with spiked helmet sign (SHS) (Figure 1). Echocardiography demonstrated neither wall motion abnormality nor tumour metastasis to the heart. Initial ECG abnormality was resolved after improvement with oxygenation (Figure 2). The patient expired after 7 h in ICU stay. SHS is characterised by an upslope of the baseline that starts before the onset and ends after termination of the QRS complex giving rise to a spike-and-dome pattern that resembles a German military spiked helmet. The mechanism of SHS is uncertain. SHS was first detected in cases of acute abdomen and thoracic pathology. As a result, it was assumed that the ECG pattern was an artefact from the voltage generated by mechanical epidermal stretch caused by a rapid increase in intra-abdominal or thoracic pressure. However, subsequent reports demonstrated SHS in cases of intracranial haemorrhage, sepsis, and metabolic derangement. A unifying description emerged in that SHS was caused by adrenergically mediated prolongation of repolarization. Such conditions were established causes of acquired long QT. The characteristic pattern may be formed by the preceding beat’s late and giant T-U waves superimposed on the QRS. When seen in the inferior leads, this ominous ECG pattern should raise the possibility of an acute abdominal event, and one should suspect an intrathoracic pathology if it shows up in the precordial leads. Although the spike and dome pattern was not clearly present in our case, we assumed that it could be SHS due to intra thoracic pathology. The clinical importance is that recognising a SHS can help avoid unnecessary emergent cardiac catheterizations. Instead, it can focus physician attention to a possible catastrophic abdominal or thoracic disease and thus help to select an appropriate, potentially life-saving strategy.