Mirror patterns

Oligoclonal bands may also be present in serum. If the CSF bands exibit a mirror pattern of the serum bands, the process is limited to the systemic compartment. A particular case is a paraprotein pattern. It is seen both in CSF and serum, either due to myeloma or so-called benign paraprotein (LI). 

The electrocardiographic patterns of ischaemia, injury and necrosis are of greatest importance in the diagnosis and prognosis of IHD. They are recorded in different leads as direct patterns, according to the affected zone. On the other hand, they may also be recorded in opposite leads as mirror patterns ... 

We should remember that in some chronic coronary patients, those who present a transmural infarction classically named inferoposterior but with the new classification we define as inferolateral MI (Figure 5.9B(3)), a tall, frequently peaked, and in this case persistent, T wave may be recorded in V1-V3 as a consequence of the changes that the transmural infarction produced in repolarization (mirror pattern of inferobasal and lateral subepicardial ischaemia) (Figure 3.10). 

Figures 3.18 and 3.19 show the evolution of two Mis from the acute phase with a huge ST-segment elevation until the appearance of Q wave of necrosis and negative T wave of subepicardial ischaemia. In Figure 3.20, a patient with chronic MI of inferior wall presents in the same ECG a different grade of ECG pattern of subepicardial ischaemia (negative and deep T wave in inferior leads, tall and positive T wave in right precordial leads as a mirror pattern and flat T wave in V6).

The negative T wave of subepicardial ischaemia is recorded in different leads, depending on the myocardial area affected by the occluded coronary artery (inferolateral or anteroseptal). In general, in case of single-vessel disease ischaemia is regional therefore, a mirror pattern may be observed in the FP (Figures 3.10 and 3.20). Much probably, ischaemia at rest is usually explained by only a culprit artery, even maybe stenosis in other arteries (multivessel disease). 

Figure 3.20 Old inferior infarction with lateral ischaemia (positive and symmetric T wave in V1-V3), with TV3 > TV1. The presence of flat T wave in V6 suggests that low lateral wall is also affected. Observe the negative T wave in II, III and VF (inferior ischaem ia) and the positive T wave in I and VL that appears as a mirror pattern.

Figure 3.28 A patient with chronic constrictive pericarditis. The T wave is negative in many leads, but not quite deep, without the mirror pattern in the frontal plane. The T wave is only positive in VR and V1 because as this is a diffuse subepicardial ischaemia, they are the only two leads in which the ischaemia vector that is directed away from the ischaemic area is approaching the exploring electrode.

When the subepicardial injury occurs in the inferior and lateral wall (LCX or RCA occlusion), the direct pattern of the ST-segment elevation is seen in inferior leads and in the leads recorded in the back (posterior thoracic leads). In these cases, often an ST-segment depression is recorded in V1-V3 leads, as a mirror pattern of ST-segment elevation recorded in the back (Figure 4.15). 

Figure 4.16 Acute myocardial infarction in a patient with rapid atrial fibrillation. The ECG shows ST-segment elevation in V2-V5, I and VL. Leads II, III, and VF present an evident ST-segment depression as a mirror pattern of ST-segment elevation in precordial leads. This is a pattern of acute coronary syndrome with ST-segment elevation of the anterior wall according to the classical classification.

Dissecting aortic aneurysm (Figure 7.4) (mirror pattern of LVH)... 

Figures 4.55 and 4.56 are examples of hyper-kalaemia and hypothermia that may also present ST-segment elevation in some leads. An ST-segment elevation may also be seen in other situations (Table 4.3), such as certain ionic or metabolic disorders, pneumothorax, etc., and, obviously, in secondary repolarisation abnormalities, such as mirror patterns (e.g. in V1-V2 in LVE or in LBBB).

Figure 7.4 (A) A patient with thoracic pain due to a dissecting aortic aneurysm. An ST-segment elevation in V1-V3 can be explained by the mirror pattern of an evident LVE (V6) due to hypertension. This ST-segment elevation has been erroneously interpreted as due to an acute coronary syndrome. As a consequence, fibrinolytic...

Recurrent ST-segment elevation, especially with pain, detected with continuous multilead ST-segment monitoring (Akkerhuis et al., 2001). -According to the ST-segment elevation in the precordial or inferior leads and the presence of mirror patterns, the ECG allows for location of the coronary... 

Myocardial damage and viability may be approximately quantified in the chronic phase of a Q-wave infarction. Different scores have been described, to know with a greater or lesser accuracy the amount of myocardium involved and, indirectly, the LV function (EF) (Palmeri et al., 1982). Selvester, Wagner and Hindman (1985) described a 31-point scoring system, on the basis of 50 criteria (presence of Q wave in different leads, R wave in V1-V2 as mirror pattern, etc.). This score quantifies the amount of infarcted tissue (3% of the left-ventricular mass for each point). Also, the reduction of the EF due to the infarction may be... 

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