Spiked Helmet Sign: An Electrocardiographic Pattern Beyond Sepsis

Background The spiked helmet sign (SHS) is a rare ECG pattern classically associated with severe non-cardiac illness and high mortality. Its occurrence in primary cardiac conditions is uncommon and remains poorly characterized. Case Presentation A 62-year-old male undergoing elective non-cardiac surgery developed hypotension followed by ventricular arrhythmias and cardiac arrest during anesthetic induction. Post-resuscitation ECG demonstrated dynamic ST-segment changes with prominent R-wave and convex ST-segment elevation, consistent with SHS morphology. The patient remained in the intensive care unit for 7 days, during which clinical recovery was favorable and no condition known to be associated with SHS was identified. Seventy-two hours after discharge, the patient presented with recurrence of chest pain accompanied by reappearance of SHS morphology. Coronary angiography demonstrated severe spontaneous right coronary artery vasospasm, coinciding with ECG changes. Initiation of calcium channel blocker therapy led to resolution of symptoms and normalization of the ECG abnormalities. Conclusions This case documents SHS occurring in the setting of coronary vasospasm and cardiac arrest, expanding its clinical spectrum beyond sepsis, intra-abdominal or intrathoracic pathologies. Recognition of this atypical and novel presentation highlights the need for further investigation into the mechanisms and clinical implications of SHS in cardiac disease.