Carotid Sinus Massage

Evaluation of Wide Complex Tachycardia

When a patient develops wide complex tachycardia, it is important to determine the cause quickly and accurately. This article will help the bedside nurse understand different causes, determine the most probable cause, and provide appropriate first-line treatment.

Bedside Carotid Sinus Massage for Syncope Evaluation With Bifascicular Block and First-Degree Atrioventricular Block

Symptomatic bifascicular block (BFB) with a reversible high-grade atrioventricular block (AVB) is an overlooked cause of syncope with differing diagnostic and therapeutic approaches. We present a case of a 79-year-old gentleman with multiple episodes of cardiac syncope. Initial electrocardiogram revealed a left bundle branch block and first-degree AVB worsened by bedside carotid sinus massage (CSM) obviating the need for electrophysiologic (EP) studies or continuous electrocardiographic monitoring for further evaluation. This case highlights the importance of CSM as a useful clinical tool in addition to EP studies and internal loop recorder (ILR) placement for assessment and appropriateness of permanent pacemaker (PPM) implantation. It also sheds light on the differing management protocols between EP studies and ILR evaluation versus empiric PPM implantation for patients with cardiac syncope secondary to BFB and AVB.

Comparison of Various Vagal Maneuvers for Supraventricular Tachycardia by Network Meta-Analysis

BACKGROUND

Vagal maneuvers (VagMs) are recommended as the first-line treatment of supraventricular tachycardia (SVT). However, the optimal type of VagMs remains unproven.

AIM

This study aims to compare the effectiveness and adverse events amongst VagMs on SVT via network meta-analyses (NMAs).

METHODS

We systematically searched randomized controlled trials (RCTs) that involved adults with SVT and compared VagMs without language restrictions. We determined the initial and final responses of conversion rate to sinus rhythm and adverse events. Risk of bias (RoB) was appraised by Cochrane revised tool, and contribution matrix was calculated. NMAs were synthesized using frequentist random-effects model and presented as relative risk (RR) with 95% CI. The order of probability was presented as surface under the cumulative ranking curve analysis (SUCRA). Sensitivity analysis was performed using both Bayesian and frequentist approach with fixed- or random-effects models. Certainty of evidence (CoE) was rated by using the Grading of Recommendations, Assessment, Development, and Evaluations methodology.

RESULTS

Fourteen RCTs with 2,180 patients were enrolled. Small portion of mixed estimates was contributed from high overall RoB studies. Compared with carotid sinus massage (CSM), the modified Valsalva maneuver (MVM) was the most effective VagM after initial performance [SUCRA: 0.9992, RR: 5.47 (1.77-16.93)] and at the end of study [SUCRA: 1.0000, RR: 3.62 (2.04-6.39), CoE: high]. The standard VM did not elicit better conversion rate to the sinus rhythm than CSM at the initial response [SUCRA: 0.4395, RR: 1.97 (0.63-6.15)] and at the end of the study [SUCRA: 0.4795, RR: 1.64 (0.94-2.87), CoE: moderate]. The SUCRA value of CSM at the initial and final responses was the least one amongst three VagMs (0.0613 and 0.0205, respectively). Adverse events amongst three VagMs were similar (CoE: low). Sensitivity analyses yielded consistent results.

CONCLUSION

We recommended MVM as the first choice of VagM for rhythm conversion before the pharmacological management of SVT.

Anterior cervical pseudomeningocele causing syncope after spinal surgery: A case report

INTRODUCTION AND IMPORTANCE

Pseudomeningocele formation from incidental durotomy is a known risk in spine surgery. We present a case of incidental durotomy leading to anterior neck pseudomeningocele, compressing the carotid body (CB) resulting in syncopal episodes. To our knowledge, this is the first case report implicating syncopal episodes to CB compression via a pseudomeningocele.

CASE PRESENTATION

A mid sixty-year-old patient with history of obesity, hypertension, and diabetes presented with gait impairment and hand weakness. Ossification of posterior longitudinal ligament (OPLL) was diagnosed with computed tomography imaging (CT) and magnetic resonance imaging (MRI). Elective surgery was completed with an anterior and posterior approach for decompression and fusion. Hospital course (San Jose, CA, USA) was complicated by respiratory depression and incomplete tetraplegia. On post-operative day (POD) six, CT revealed anterolateral soft tissue neck swelling; subsequent CT and MRI showed fluid collection expansion, with associated syncopal episodes on POD thirty-nine. Despite interventional radiology drainage, the fluid collection and symptoms returned five days later. The patient ultimately underwent durotomy revision and repair with muscle patch.

CLINICAL DISCUSSION

This case highlights the challenges in managing anterior cervical dural tears resulting in pseudomeningocele. Risk factors include anterior cervical corpectomy and decompression, as well as an underlying diagnosis of OPLL. Untreated dural tears may develop into pseudomeningoceles which can contribute to life-threatening outcomes.

CONCLUSION

This case report presents the serious consequences of incidental durotomy, the unique post-surgical complication of syncope due to compression of the CB from a pseudomeningocele, and the challenges of managing a persistent pseudomeningocele.

Air Pollution Role as Risk Factor of Cardioinhibitory Carotid Hypersensitivity

Little is known about the impact of air pollution on neuroautonomic system. The authors have investigated possible influence of air pollution and outdoor temperature on the carotid sinus hypersensitivity (CSH), as main cause of neurally mediated syncope in forty-years-old subjects and older. Pollutants’ concentrations and outdoor temperature of days in which 179 subjects with recurrent syncope underwent carotid sinus massage (CSM) were analyzed. Before this manoeuvre, cardiovascular control by short period heart and blood pressure spectral duration of segment between the end of P and R ECG-waves (PeR) were registred; RR variability on the same short period ECG recordings and their spectral coherence were also analyzed. CSH was found in 57 patients (28 with cardioinhibitory response and 29 subjects showed vasodepressor reaction), while 122 subjects had a normal response. CSM performed during high ozone concentrations was associated with slightly higher risk of cardioinhibitory response (odd ratio 1.012, 95% CI 1.001–1.023, p < 0.05), but neither this or other polluting agent nor outdoor temperature seemed to influence autonomic control in basal resting condition. Thus, ozone seemed to influence response to the CSM in CSH patients and it is probably able to facilitate a cardioinhibitory response, perhaps through an increase of nerve acetylcholine release. P→PR coherence could be useful in predicting a sinus cardioinhibitory hypersensitivity in those cases when CSM is contraindicated.

Left hemispheric cortical watershed infarcts triggered by carotid sinus self-massage

A 69-year-old man was presented to our emergency department with acute onset of hemianopsia, aphasia and dizziness. He reported that while he was sitting in front of his computer at home, he had performed a bilateral self-massage of his carotid arteries when suddenly the symptoms occurred. A neurological examination revealed a hemianopsia with a visual field loss on the right side. In addition, a mild aphasic syndrome with agraphia and a word-finding disorder (National Institutes of Health Stroke Scale (NIHSS): 3 points) was diagnosed. The initial brain CT scan with CT angiography showed neither an intracerebral haemorrhage nor a cerebral infarction. Also, no occlusion or any signs of artery dissection or a flow relevant stenosis of the brain supplying arteries were found. After excluding other contraindications, an intravenous thrombolysis with weight-adapted alteplase was performed. The symptoms of the patient significantly improved in the short-term follow-up. Three days after admission no neurological deficits remained. The MRI of the brain revealed multifocal, small, left hemispherical strokes in the middle cerebral artery territory. In general, watershed infarcts after carotid sinus self-massage follow a rare ischaemic stroke mechanism. This case emphasises the importance of a detailed anamnestic evaluation to determine the aetiological classification of ischaemic stroke as well as educating patients' (poststroke) behaviour.

Recommendations for tilt table testing and other provocative cardiovascular autonomic tests in conditions that may cause transient loss of consciousness : Consensus statement of the European Federation of Autonomic Societies (EFAS) endorsed by the American Autonomic Society (AAS) and the European Academy of Neurology (EAN)

An expert committee was formed to reach consensus on the use of tilt table testing (TTT) in the diagnosis of disorders that may cause transient loss of consciousness (TLOC) and to outline when other provocative cardiovascular autonomic tests are needed. While TTT adds to history taking, it cannot be a substitute for it. An abnormal TTT result is most meaningful if the provoked event is recognised by patients or eyewitnesses as similar to spontaneous events. The minimum requirements to perform TTT are a tilt table, a continuous beat-to-beat blood pressure monitor, at least one ECG lead, protocols for the indications stated below and trained staff. This basic equipment lends itself to the performance of (1) additional provocation tests, such as the active standing test, carotid sinus massage and autonomic function tests; (2) additional measurements, such as video, EEG, transcranial Doppler, NIRS, end-tidal CO2 or neuro-endocrine tests; and (3) tailor-made provocation procedures in those with a specific and consistent trigger of TLOC. TTT and other provocative cardiovascular autonomic tests are indicated if the initial evaluation does not yield a definite or highly likely diagnosis, but raises a suspicion of (1) reflex syncope, (2) the three forms of orthostatic hypotension (OH), i.e. initial, classic and delayed OH, as well as delayed orthostatic blood pressure recovery, (3) postural orthostatic tachycardia syndrome or (4) psychogenic pseudosyncope. A therapeutic indication for TTT is to teach patients with reflex syncope and OH to recognise hypotensive symptoms and to perform physical counter manoeuvres.

Recommendations for tilt table testing and other provocative cardiovascular autonomic tests in conditions that may cause transient loss of consciousness : Consensus statement of the European Federation of Autonomic Societies (EFAS) endorsed by the American Autonomic Society (AAS) and the European Academy of Neurology (EAN)

An expert committee was formed to reach consensus on the use of Tilt Table Testing (TTT) in the diagnosis of disorders that may cause transient loss of consciousness (TLOC) and to outline when other provocative cardiovascular autonomic tests are needed. While TTT adds to history taking, it cannot be a substitute for it. An abnormal TTT result is most meaningful if the provoked event is recognised by patients or eyewitnesses as similar to spontaneous ones. The minimum requirements to perform TTT are a tilt table, a continuous beat-to-beat blood pressure monitor, at least one ECG lead, protocols for the indications stated below and trained staff. This basic equipment lends itself to perform (1) additional provocation tests, such as the active standing test carotid sinus massage and autonomic function tests; (2) additional measurements, such as video, EEG, transcranial Doppler, NIRS, end-tidal CO₂ or neuro-endocrine tests; (3) tailor-made provocation procedures in those with a specific and consistent trigger of TLOC. TTT and other provocative cardiovascular autonomic tests are indicated if the initial evaluation does not yield a definite or highly likely diagnosis, but raises a suspicion of (1) reflex syncope, (2) the three forms of orthostatic hypotension (OH), i.e. initial, classic and delayed OH, as well as delayed orthostatic blood pressure recovery, (3) postural orthostatic tachycardia syndrome or (4) psychogenic pseudosyncope. A therapeutic indication for TTT is to teach patients with reflex syncope and OH to recognise hypotensive symptoms and to perform physical counter manoeuvres.

[Syncopes]

Syncopes are defined as sudden and short unconsciousness with loss of muscular tonus which are reversible without further intervention. Differentiation from other short-lasting changes of consciousness as in seizures, blood flow abnormalities of brainstem, metabolic disorders, intoxication or traumatic loss of consciousness is important for further diagnostic and adequate treatment.

Massage du sinus carotidien

Le massage du sinus carotidien (MSC) est un geste simple, utilisé en médecine d’urgence à visées diagnostique et/ou thérapeutique. Les indications principales au MSC sont l’évaluation des syncopes chez les patients de plus de 40 ans et le traitement de première ligne des tachycardies paroxystiques supraventriculaires bien tolérées hémodynamiquement. Les contre-indications incluent un antécédent d’accident vasculaire cérébral ou d’accident ischémique transitoire dans les trois mois qui précèdent ainsi que la présence d’une sténose carotidienne significative ou d’un souffle carotidien. Dans le bilan de la syncope, le MSC permet de diagnostiquer une hypersensibilité du sinus carotidien. Pour les tachycardies supraventriculaires, il permet de préciser le type de tachycardie et, dans certains cas, d’obtenir une restauration d’un rythme sinusal. Les rares complications sont liées au risque de provoquer une embolie cérébrale.