Neurogenic ST-segment elevation following acute ischemic stroke with hemorrhagic transformation: a case report

Background: Neurogenic ST-segment elevation is a rare but clinically significant cardiac manifestation that can occur after acute ischemic stroke with hemorrhagic transformation. It may closely mimic acute ST-elevation myocardial infarction (STEMI), leading to potentially inappropriate diagnostic or therapeutic interventions. Case presentation: We report on a 46-year-old man who presented with right-sided weakness and expressive aphasia for 1 day. He had a history of untreated hypertension. On admission, vital signs were notable for a BP of 190/100 mmHg and an HR of 100 bpm. The ECG revealed ST-segment elevation in leads V1–V4. Brain MRI confirmed an acute left parietotemporal ischemic stroke with hemorrhagic transformation. Echocardiography showed preserved left ventricular function with mild hypertrophy. Laboratory tests revealed elevated troponin and BNP levels. Given stable hemodynamics and the absence of regional wall motion abnormalities, cardiology recommended conservative management with close monitoring. Management and outcome: The patient received antihypertensive therapy, mannitol infusion, head-of-bed elevation, and physiotherapy. Serial ECG monitoring demonstrated resolution of ST-segment elevation by day 5. Neurological improvement was progressive, and the patient was discharged after 8 days with follow-up recommendations. Discussion: This case highlights a reversible pattern of ST-segment elevation secondary to neurogenic myocardial injury following acute ischemic stroke with hemorrhagic transformation. Recognition of this phenomenon is essential to avoid misdiagnosis and unnecessary cardiac interventions. Conclusion: In patients with acute ischemic stroke and hemorrhagic transformation presenting with ECG changes suggestive of STEMI, integrated neurological and cardiac assessment with serial ECG and biomarker monitoring is crucial to guide safe management and prevent iatrogenic harm.