Case Report
Copyright ©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Jan 6, 2024; 12(1): 148-156
Published online Jan 6, 2024. doi: 10.12998/wjcc.v12.i1.148
Subarachnoid hemorrhage misdiagnosed as acute coronary syndrome leading to catastrophic neurologic injury: A case report
Jun-Ming Lin, Xiao-Jun Yuan, Guang Li, Xin-Rong Gan, Wen-Hua Xu
Jun-Ming Lin, Xiao-Jun Yuan, Guang Li, Xin-Rong Gan, Wen-Hua Xu, Department of Orthopaedic Surgery, People's Hospital of Yichun City, Yichun 336000, Jiangxi Province, China
Co-first authors: Jun-Ming Lin and Xiao-Jun Yuan.
Author contributions: Lin JM was responsible for conceptualization, methodology, formal analysis, and writing of the original draft; Yuan XJ was responsible for conceptualization, data curation, and validation; Li G was responsible for formal analysis; Gan XR was responsible for project administration and supervision; Xu WH was responsible for project administration, supervision, and manuscript review and editing. Lin JM and Yuan XJ contributed equally to this work as co-first authors. Lin JM was responsible for conceptualization, methodology, formal analysis, and writing the original manuscript; Yuan XJ was responsible for conceptualization, data compilation, validation, and review of the manuscript. In summary, we believe that designating Lin JM and Yuan XJ as co-first authors is fitting for our manuscript as it accurately reflects our team's collaborative spirit, equal contributions, and diversity.
Informed consent statement: The patient provided informed written consent about personal and medical data collection prior to study enrolment.
Conflict-of-interest statement: All the authors have no conflict of interest related to the manuscript.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Wen-Hua Xu, MD, Department of Orthopaedic Surgery, People's Hospital of Yichun City, No. 1061 Jinxiu Avenue, Yiyang New District, Yichun 336000, Jiangxi Province, China. 1597504790@qq.com
Received: September 5, 2023
Peer-review started: September 5, 2023
First decision: November 22, 2023
Revised: November 30, 2023
Accepted: December 19, 2023
Article in press: December 19, 2023
Published online: January 6, 2024
Abstract
BACKGROUND

Elevated levels of cardiac troponin and abnormal electrocardiogram changes are the primary basis for clinical diagnosis of acute coronary syndrome (ACS). Troponin levels in ACS patients can often be more than 50 times the upper reference limit. Some patients with subarachnoid hemorrhage (SAH) also show electrocardiogram abnormalities, myocardial damage, and elevated cardiac biomarkers. Unlike ACS patients, patients with SAH only have a slight increase in troponin, and the use of anticoagulants or antiplatelet drugs is prohibited. Because of the opposite treatment modalities, it is essential for clinicians to distinguish between SAH and ACS.

CASE SUMMARY

A 56-year-old female patient was admitted to the emergency department at night with a sudden onset of severe back pain. The final diagnosis was intraspinal hematoma in the thoracic spine. We performed an emergency thoracic spinal canal hematoma evacuation procedure with the assistance of a microscope. Intraoperatively, diffuse hematoma formation was found in the T7-T10 spinal canal, and no obvious spinal vascular malformation changes were observed. Postoperative head and spinal magnetic resonance imaging (MRI) showed a small amount of SAH in the skull, no obvious abnormalities in the cervical and thoracic spinal canals, and no abnormal signals in the lumbar spinal canal. Thoracoabdominal aorta computed tomography angiography showed no vascular malformation. Postoperative motor system examination showed Medical Research Council Scale grade 1/5 strength in both lower extremities, and the patient experienced decreased sensation below the T12 rib margin and reported a Visual Analog Scale score of 3.

CONCLUSION

Extremely elevated troponin levels (more than 50 times the normal range) are not unique to coronary artery disease. SAH can also result in extremely high troponin levels, and antiplatelet drugs are contraindicated in such cases. Emergency MRI can help in the early differential diagnosis, as a misdiagnosis of ACS can lead to catastrophic neurological damage in patients with spontaneous spinal SAH.

Keywords: Acute coronary syndrome, Spontaneous spinal subdural hematoma, Misdiagnosis, Catastrophic neurological injury, Case report

Core Tip: Elevated cardiac troponin levels and abnormal electrocardiographic changes are the primary basis for the clinical diagnosis of acute coronary syndrome (ACS). Some patients with subarachnoid hemorrhage (SAH) have similar features. Unlike patients with ACS, patients with SAH have only mildly elevated troponin, and antiplatelet agents are contraindicated. We report for the first time a patient with spontaneous spinal SAH of unknown etiology, who was misdiagnosed as having ACS because of severe back pain, very high troponin levels, and abnormal electrocardiographic changes, and who developed catastrophic neurological damage after treatment with oral antiplatelet agents.