Invest Clin 64(4): 533 - 538, 2023 https://doi.org/10.54817/IC.v64n4a10

Corresponding author: Jianming Zhang. Department of ECG Room, Shaoxing People’s Hospital, Shaoxing 312000,

Zhejiang Province, China. E-mail: zjsxzjm@163.com

Evaluation of myocardial infarction

by a 12-lead routine electrocardiogram:

a case report of an ST-segment elevation.

Huayong Jin, Lijiang Ding, Binglei Li and Jianming Zhang

Department of ECG Room, Shaoxing People’s Hospital, Zhejiang Province, China.

Keywords: electrocardiogram; spiked helmet sign; ST-segment elevation; myocardial

infarction.

Abstract. The spiked helmet sign (SHS) is a type of ST-segment elevation

associated with critical cardiac disease and a high risk of death. We report a

case of SHS caused by an ECG artifact. A 60-year-old male patient presented

to the clinic after suffering an electric shock. The initial 12-lead routine elec-

trocardiogram showed an SHS. The patient received appropriate intravenous

fluid replacement therapy, and after 30 minutes, the ST-T changes of the 12-

lead electrocardiogram were all restored to normal. The patient was discharged

after a 24-hour observation period in the emergency room. Recent studies have

pointed out that there may be two different types of SHS. One is the mechanical

factor, and the other is the significant prolongation of the QT interval. The two

types have different clinical significance. In our report, the radial artery of the

patient’s right wrist pulsed strongly, and after the occurrence of SHS, the SHS

disappeared after adjusting the contact position of the electrode in his right

arm. This SHS caused by mechanical traction was an ECG artifact. Although

the SHS may be an essential indicator of critical illness, there are mechanical

factors that lead to the appearance of ECG artifacts. Therefore, in clinical work,

obtaining a complete medical history and primary conditions of the patient at

the time of ECG sampling is necessary to help the diagnosis and thus avoid er-

roneous treatment.

534 Jin et al.

Investigación Clínica 64(4): 2023

Evaluación del infarto de miocardio mediante

un electrocardiograma de rutina de 12 derivaciones:

reporte de un caso de elevación del segmento ST.

Invest Clin 2023; 64 (4): 533 – 538

Palabras clave: electrocardiograma; signo del casco prusiano; elevación del segmento

ST; infarto del miocardio.

Resumen. El signo del casco prusiano (signo del casco con púa-SHS) es

un tipo de elevación del segmento ST asociado con enfermedad cardíaca crítica

y un alto riesgo de muerte. Presentamos un caso de SHS causado por un arte-

facto del ECG. Un paciente varón de 60 años acudió a la clínica tras sufrir una

descarga eléctrica. El electrocardiograma de rutina inicial de 12 derivaciones

mostró un SHS. El paciente recibió una terapia de reposición de líquidos por

vía intravenosa adecuada y, después de 30 minutos, los cambios ST-T del elec-

trocardiograma de 12 derivaciones se normalizaron. El paciente fue dado de

alta después de un período de observación de 24 horas en la sala de emergen-

cias. Estudios recientes han señalado que puede haber dos tipos diferentes de

SHS. Uno debido a un factor mecánico y el otro es la prolongación significativa

del intervalo QT. Los dos tipos tienen un significado clínico diferente. En nues-

tro reporte, la arteria radial de la muñeca derecha del paciente pulsaba con

fuerza, y después de la aparición del SHS, este desapareció después de ajustar

la posición de contacto del electrodo en su brazo derecho. Este SHS causado

por tracción mecánica era un artefacto del ECG. Aunque el SHS puede ser un

indicador esencial de enfermedad crítica, existen factores mecánicos que con-

ducen a la aparición de artefactos en el ECG. Por lo tanto, en la práctica clínica,

es necesario obtener una historia clínica completa y observar las condiciones

primarias del paciente en el momento de la toma de muestras del ECG para

ayudar al diagnóstico y así evitar un tratamiento erróneo.

Received: 19-06-2023 Accepted: 05-08-2023

INTRODUCTION

The ST-segment elevation is typical in

acute myocardial infarction. In 2011, Lit-

tmann et al. reported a particular type of

ST-segment elevation, which presented as

ST-segment inferior oblique elevation with

baseline superior oblique elevation of the

QRS wavefront and a sharp R wave. Because

of its graphic characteristics similar to the

shape of the pointed helmet used by German

soldiers, this electrocardiogram (ECG) find-

ing was named the spiked helmet sign (SHS)

1. In the existing literature, SHS is usually as-

sociated with critical illnesses such as acute

myocardial infarction and predicts very poor

clinical outcomes, including death2,3. Howev-

er, the mechanism and clinical significance

of SHS is still unclear.

ECG artifacts caused by various inter-

ferences are often encountered in clinical

work 4. Although common interferences

can be identified in combination with ECG

morphology and clinical manifestations of

Evaluation of myocardial infarction with ST-segment elevation 535

Vol. 64(4): 533 - 538, 2023

patients, some can also manifest as severe

heart diseases, such as acute myocardial

infarction, which is difficult for even expe-

rienced clinicians to identify. This case re-

ports the ECG manifestations of a patient

who initially developed false SHS after an

electric shock.

CASE DESCRIPTION

A 60-year-old man with no previous his-

tory of critical illness presented with head,

chest, hip, and left elbow pain one hour af-

ter a fall. The patient was found lying on the

ground at work one hour before. The patient’s

co-workers claimed that he was injured due

to a fall. The patient recalled the scene then

and claimed that an electric shock caused it.

The patient had an episode of transient coma

and recovered spontaneously without nau-

sea, vomiting, convulsions, or dyspnea. At the

time of presentation, the patient’s tempera-

ture was 36.6 °C, heart rate was 90 beats per

minute, blood pressure was 150/70 mmHg,

and oxygen saturation was 95%. The results of

the physical examination were mild respirato-

ry sounds in both lungs, normal heart sounds,

no evident murmur, warm limbs, about 1% of

a third-degree burn area on the forearm of

the left upper limb, movable limbs, and pal-

pable dorsalis pedis artery pulsation. A CT

scan of the skull revealed swelling of the right

scalp soft tissue. Creatine kinase and cre-

atine kinase-MB were 953.7U/L and 27U/L,

respectively, which were higher than normal

values. A 12-lead electrocardiogram (Fig. 1)

revealed an SHS: lead (I, II, AVL, and AVF)

showed an ST elevation of 0.05–0.1 mV with

T-wave inversion, the lead AVR showed an ST

depression of 0.05mm with T-wave bidirec-

tional changes, and QT interval extended to

460 ms. During this period, the radial artery

of the patient’s right wrist pulsated strongly,

and the SHS phenomenon disappeared after

adjusting the contact position of the right

arm electrode. After that, the patient received

appropriate intravenous rehydration therapy.

After 30 minutes, the 12-lead electrocardio-

gram (Fig. 2) was reviewed, and all the ST-T

changes in the electrocardiogram returned to

normal. The patient was discharged without

any abnormality after 24 hours of observation

in the emergency department.

Fig. 1. The patient presented with a 12-lead routine ECG. Arrows indicate ST elevation of 0.05-0.1mv with T-

wave inversion in leads I, II, AVL, and AVF, and ST depression of 0.05mv in lead AVR with bidirectional

changes in T-wave.

536 Jin et al.

Investigación Clínica 64(4): 2023

DISCUSSION

In the twelve years since the SHS was

first reported in 2011, several communica-

tions have portrayed the SHS as an indicator

of critical illness and poor prognosis, with an

alarming post-emergence mortality rate of

59% 5. However, recent studies have divided

the SHS into two types. The prolongation of

the QT interval causes one, and the other is

caused by the superposition of mechanical

factors, which may be an ECG artifact 6.

Experimental data show that physical

stretching of the skin can produce a voltage

of several millivolts 7. The conductivity of ion

channels in the heart will be changed under

the pull of different tensions, affecting myo-

cardial cells’ action potential and changing

the ECG pattern 8. In addition, recent stud-

ies support the conclusion that mechani-

cal factors contribute to the SHS. When

Tomcsányi et al. placed the ECG lead over

the arteriovenous fistula in the left arm of a

hemodialysis patient, the ECG showed SHS,

whereas when the electrodes were placed

further on the normal epidermis, the SHS

disappeared, meaning that SHS was caused

by pulsatile epidermal stretching 6. Agarwal

et al. reported that an SHS appeared in the

ECG of a 77-year-old male patient who used

mechanical ventilation when the pressure

in the chest cavity increased, obviously due

to excessive positive end-expiratory pres-

sure, but disappeared after reducing positive

end-expiratory pressure 9. In this case, when

compared with the ECG image in Fig. 1, we

found no dynamic changes in ST-T in Lead

III. According to Einstein’s triangle theory,

Lead III was the potential difference between

the left arm and left leg. When the artifact

came to the right arm, there was an interfer-

ence artifact in leads I and II, and Lead III

remained normal. The patient’s right wrist

radial artery was beating strongly, and the

ECG showed SHS, whereas the ECG disap-

peared after adjusting the position of the

right arm electrode contact, similar to the

case reported by Tomcsányi 10. Therefore,

in our case, the SHS was an ECG artifact

caused by mechanical traction.

The SHS phenomenon can be produced

when limb lead electrodes are placed on the

radial artery, indicating acute ST-segment

elevation muscular infarction (STEMI). Al-

though an SHS may be an essential indicator

of critical diseases, we must identify other

Fig. 2. The patient’s ECG reviewed after 30 minutes. ST-T in leads I, II, AVR, AVL, and AVF returned to normal.

Evaluation of myocardial infarction with ST-segment elevation 537

Vol. 64(4): 533 - 538, 2023

conditions that can cause SHS and remain

vigilant. Obtaining a complete medical his-

tory and the patient’s basic situation during

ECG sampling can help clarify the truth of

ECG performance, thus avoiding wrong di-

agnosis and over-treatment.

Conflict of competence

The authors declare no conflict of in-

terest.

Funding

The research is supported by 2022 Zhe-

jiang Provincial Health Science and Technol-

ogy Plan, Promotion and Application of ECG

Remote Intelligent Network Transmission

and Report Writing Standards in Grassroots

Hospitals (No.: 2022ZH061).

Authors’ Orcid Number

• Huayong Jin (HJ):

0009-0008-2326-5884

• Lijiang Ding (LD):

0009-0006-1889-1384

• Binglei Li (BL):

0009-0005-5803-120X

• Jianming Zhang (JZ):

0009-0007-1433-8087

Contribution of authors to the papers

Substantial contributions to concep-

tion and design: HJ, LD. Data acquisition,

data analysis, and interpretation: BL, JZ.

Drafting the article or critically revising it

for important intellectual content: HJ, LD.

Final approval of the version to be published:

All authors. Agreement to be accountable for

all aspects of the work in ensuring that ques-

tions related to the accuracy or integrity of

the work are appropriately investigated and

resolved: Huayong Jin, Lijiang Ding, Binglei

Li, Jianming Zhang. Huayong Jin and Lijiang

Ding contributed equally to this work as co-

first authors.

REFERENCES

1. Littmann L, Monroe MH. The “spiked

helmet” sign: A new electrocardiographic

marker of critical illness and high risk of

death. In: Mayo Clin Proc 2011;86:1245-

1246. https://doi.org/10.4065/mcp.2011.

0647.

2. Hamade H, Jabri A, Yusaf A, Nasser MF,

Karim S. The spiked helmet sign: a con-

cerning electrocardiographic finding.

JACC Case Reports 2021; 3(11): 1370-

1372. https://doi.org/10.1016/j.jaccas.20

21.04.048.

3. Oluyadi F, Theetha Kariyanna P, Jaya-

rangaiah A, Celenza-Salvatore J, M. Mc-

Farlane I. Helmet sign on EKG: a rare in-

dicator of poor prognosis in critically ill

patients. Am J Med Case Reports 2019;

7(10): 260-263. https://doi.org/10.12691/

ajmcr-7-10-9.

4. Littmann L. Electrocardiographic arti-

fact. J Electrocardiol 2021; 64: 23-29.

https://doi.org/10.1016/j.jelectrocard.20

20.11.006.

5. Mahmoudi E, Hui JMH, Leung KSK, Satti

DI, Athena Lee YH, Christien Li KH, Hei

Lau DH, Ming Kot TK, Ciobanu A, Ba-

zoukis G, Kai Chan JSh, Baranchuk A.

Spiked helmet rlectrocardiographic sign-A

systematic review of case reports. Curr Pro-

bl Cardiol 2023; 48(3): 101535. https://

doi.org/10.1016/j.cpcardiol.2022.101535.

6. Tomcsányi J, Bózsik B. Two forms of the

spiked helmet sign are caused by two sepa-

rate mechanisms. J Electrocardiol 2022;

73: 129-130. https://doi.org/10.1016/j.

jelectrocard.2019.07.012.

7. Edelberg R. Local electrical response

of the skin to deformation. J Appl Physi-

ol 1973; 34(3): 334-340. https://doi.

org/10.1152/jappl.1973.34.3.334.

8. Weise LD, Panfilov AV. Correction: A dis-

crete electromechanical model for human

cardiac tissue: Effects of stretch-activated

currents and stretch conditions on restitu-

tion properties and spiral wave dynamics.

PLoS One 2013; 8(6): e59317. https://doi.

org/10.1371/annotation/9ceadf50-eb8f-

4051-9e41-772884d47385.

538 Jin et al.

Investigación Clínica 64(4): 2023

9. Agarwal A, Janz TG, Garikipati N V. Spiked

helmet sign: An under-recognized elec-

trocardiogram finding in critically ill pa-

tients. Indian J Crit Care Med 2014; 18(4):

238-240. https://doi.org/10.4103/0972-

5229.130576.

10. Tomcsányi J. EKG-gyöngyszem: akut co-

ronaria szindróma gyanúját keltő EKG-

műtermék–poroszsisak-jel. Orv Hetil 2021;

162(34): 1383-1385.