ECG Diagnosis: Deep T Wave Inversions Associated with Intracranial Hemorrhage

ECG Diagnosis: Deep T Wave Inversions  Associated with Intracranial Hemorrhage


Joel T Levis, MD, PhD, FACEP, FAAEM

Perm J 2017;21:16-049 [Full Citation]
E-pub: 11/07/2016


The 12-lead electrocardiogram (ECG) in patients with acute intracranial hemorrhage (ICH) can demonstrate several findings associated with ICH and increased intracranial pressure, including deep, inverted “cerebral” T waves, prolonged QT interval, Osborn (J) waves, and U waves.1-3 In addition to the ECG changes described above, cardiac dysrhythmias have been reported in patients with ICH (particularly with subarachnoid hemorrhage), including: sinus bradycardia; sinus tachycardia; atrial pacemaker and atrial fibrillation; premature atrial, junctional, and ventricular complexes; ventricular tachycardia; and atrioventricular blocks.4 ST-T wave changes associated with myocardial ischemia (ST-depression) and infarction (ST-elevation) can also be found on the ECG in association with ICH. The mechanism(s) responsible for ECG changes associated with ICH are not well understood, although hypothalamic stimulation and autonomic dysregulation have been implicated as causative for these ECG findings.4

The differential diagnosis of inverted T waves on the 12-lead ECG includes myocardial ischemia and infarction, bundle branch block, ventricular hypertrophy, pulmonary embolism, hypertrophic cardiomyopathy, and increased intracranial pressure.5 It is important to note that the findings of deep, inverted T waves on the 12-lead ECG are not diagnostic of ICH but can occur in the appropriate clinical setting, and that further diagnostic imaging (ie, noncontrast computed tomography scan of the brain) is required for the diagnosis of ICH.

ECG Diagnosis: Deep T Wave Inversions  Associated with Intracranial Hemorrhage

ECG Diagnosis: Deep T Wave Inversions  Associated with Intracranial Hemorrhage

Disclosure Statement

The author(s) have no conflicts of interest to disclose.


Kathleen Louden, ELS, of Louden Health Communications provided editorial assistance.

How to Cite this Article


1.    Sommargren CE. Electrocardiographic abnormalities in patients with subarachnoid hemorrhage. Am J Crit Care 2002 Jan;11(1):48-56.
2.    Khechinashvili G, Asplund K. Electrocardiographic changes in patients with acute stroke: a systemic review. Cerebrovasc Dis 2002;14(2):67-76. DOI:
3.    Milewska A, Guzik P, Rudzka M, et al. J-wave formation in patients with acute intracranial hypertension. J Electrocardiol 2009 Sep-Oct;42(5):
420-3. DOI:
4.    Chatterjee S. ECG changes in subarachnoid haemorrhage: a synopsis. Neth Heart J 2011 Jan;19(1):31-4. DOI:

etoc emailClick here to join the eTOC list or text TPJ to 22828. You will receive an Email notice with the Table of Contents of each issue.

The Permanente Journal advances knowledge in scientific research, clinical medicine and innovative health care delivery. It is a peer-reviewed journal of medical science, social science in medicine, and medical humanities.

The Permanente Press

The Permanente Press publishes The Permanente Journal and books related to health care. For information about subscriptions, missing issues, billing, subscription renewal, and back issues, Email:


27,000 print readers per quarter, 15,350 eTOC readers, and in 2018, 2 million page views of TPJ articles in PubMed from a broad international readership.


The Kaiser Permanente National CME Program designates this journal-based CME activity for 4 AMA PRA Category 1 Credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ISSN 1552-5767 Copyright © 2019

All Rights Reserved.