A Twist of Fate: Torsades de Pointes Following Left Insular Stroke
Document Type
Conference Proceeding
Publication Date
4-1-2025
Publication Title
Journal of the American College of Cardiology
Abstract
Background: Torsades de Pointes (TdP) is a life-threatening form of ventricular tachycardia that occurs in patients with a prolonged QT interval. While acute strokes are known to cause various EKG abnormalities, including QT prolongation, ST-segment changes, and T-wave inversions, TdP is a rarely reported complication, with only two documented cases in the literature. Case: A 75-year-old female with no prior cardiac history presented with expressive aphasia, prompting a stroke workup. Brain MRI confirmed an acute ischemic stroke of the left insular cortex; however, thrombolytics were withheld due to a low NIHSS score. Initially, she had a normal sinus rhythm with a QTc of 438 ms. However, the next day, she experienced dizziness and telemetry revealed TdP. A 12-lead EKG showed a significantly prolonged QTc of 685 ms, which had not been present earlier. Decision-making: She was treated with IV magnesium, and started on isoproterenol and lidocaine drips. Upon further monitoring, her QTc normalized to 460 ms, the drips were gradually weaned off, and she was eventually discharged with mexiletine. Of note, her echocardiogram on admission showed a reduced ejection fraction of 25%, but it improved to 50% on discharge. Cardiac catheterization revealed non-obstructive coronary artery disease, ruling out ischemic heart disease. Other common causes of QT prolongation, such as electrolyte imbalances, drug reactions, and thyroid abnormalities were also ruled out. We suspect that the arrhythmia was neurogenic as it resolved after the ischemic event passed and due to the location of the infarct. The insular cortex is known to regulate cardiovascular function, with the right side increasing sympathetic tone and the left side enhancing parasympathetic tone. In this case, unopposed right insular activity likely triggered the arrhythmia. Conclusion: To our knowledge, this is the first reported case of TdP resulting from a left insular cortex infarction. This case underscores the importance of telemetry following an acute stroke and highlights the need for further research to identify which brain cortices are at higher risk of developing life-threatening arrhythmias.
Volume
85
Issue
12 Suppl
First Page
3671
Last Page
3671
Recommended Citation
Alakhras H, Darmadi M, Sankar PR, Bilolikar A. A twist of fate: Torsades de Pointes following left insular stroke. J Am Coll Cardiol. 2025 Apr 1;85(12 Suppl):3671. doi:10.1016/S0735-1097(25)04155-5
DOI
10.1016/S0735-1097(25)04155-5
Comments
American College of Cardiology Meeting, March 29-31, 2025, Chicago, IL