Basilar artery aneurysm: an unusual cause of intractable hiccups

Intractable hiccups caused by syringobulbia and syringomyelia associated with intramedullary spinal hemangioblastoma

INTRODUCTION

Hiccups caused by a neoplasm in the spinal cord are rare.

MATERIALS AND METHODS

We report a case of intractable hiccups caused by syringobulbia and syringomyelia associated with cervical intramedullary spinal hemangioblastoma, which was successfully treated by surgical excision. A 60-year-old man was referred from the neurology department after presenting with hiccups for 1 year. The hiccups were aggravated 3 months ago and were sustained during eating or sleeping. Several doctors administered a muscle relaxant and an anticonvulsant, but they were ineffective. Spinal MRI revealed a huge syringomyelia from C2 to T2, associated with a highly enhancing intramedullary mass lesion at the C5 level. The hiccups were ceased after removal of the tumor through a right hemilaminectomy. The pathology of the specimen was hemangioblastoma. The size of the syringobulbia and syringomyelia decreased markedly on MRI checked 5 months after surgery.

CONCLUSIONS

Intractable hiccups can be caused by syringobulbia associated with an intramedullary cord tumor in the cervical area and possible mechanisms of hiccups were reviewed.

A healthy man with intractable hiccups

We present a patient with intractable hiccups. Medical treatment decreased the frequency of the hiccups to only 5-10 per minute. After exclusion of gastrointestinal reasons for the hiccups, cranial MRI revealed a small lesion in the right rhomboid fossa, close to the vagal trigone. Microsurgical resection of the lesion was performed via a suboccipital median craniotomy. The histopathological diagnosis was a cavernoma. Promptly after surgery the patient was free of symptoms. Intractable hiccups can be associated with intracranial pathologies, including lesions in the brain stem, which we highlight with the presentation of this patient.

Hiccup and neurosurgeons: a report of 4 rare dorsal medullary compressive pathologies and review of the literature

OBJECTIVE

The aim of this study was to present 4 rare cases of medullary compressive lesions presenting with IH, to discuss the indications for neurosurgical decompression in such cases, and to review the possible etiologies of IH briefly.

METHODS

The reported cases include (1) a 19-year-old adolescent boy and a 21-year-old man with Chiari I malformation and cervical syrinx compressing or tightening the cervico-medullary junction; (2) a 35-year-old man with ependymoma extending from the lower half of the fourth ventricle to C1/C2 junction and compressing this part of the medulla; and (3) a 16-year-old adolescent boy who was referred to the emergency department in severe distress because of IH, occurring as a result of a distal PICA aneurysm located on the floor of the lower triangle of the fourth ventricle.

RESULTS

Surgical decompression in all the cases was successful in withholding the hiccups.

CONCLUSION

The dorsal medullary area is not an unusual location for genesis of hiccup. When encountering a case of IH, appropriate CNS imaging studies should be included in the evaluation protocol.

Management of hiccups in the palliative care population

There are close to a hundred causes for hiccups, or singultus, the most common of which are gastrointestinal. Causes may be natural or drug induced, and the same agents that are used to treat hiccups may also induce them. Hiccups can be classified by their duration, as follows: up to 48 hours, acute; longer than 48 hours, persistent; and more than two months, intractable. Treatment options for hiccups can include both pharmacologic and nonpharmacologic agents. If the cause of hiccups can be identified, it is, of course, preferable to direct the treatment at that cause. However many times a cause cannot be identified; in this case, general measures or treatments should be instituted. Intractable hiccups can occur in the palliative care population. When they do, it can be extremely distressing and have a significant impact on quality of life. Pharmacologic approaches are often the most rational therapies for these patients. Baclofen seems to be a promising drug for use with both palliative care and perioperative patients, and using garabentin as an add-on to baclofen may also be a reasonable option to consider