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Jansen S, van der Velde N. Syncope in older adults: challenges, approach and treatment. Age Ageing 2024; 53:afad245. [PMID: 38331395 DOI: 10.1093/ageing/afad245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Indexed: 02/10/2024] Open
Abstract
Syncope can have devastating consequences, resulting in injuries, accidents or even death. In our ageing society, the subsequent healthcare usage, such as emergency room presentations, surgeries and hospital admissions, forms a significant and growing socioeconomic burden. Causes of syncope in the older adult include orthostatic hypotension, carotid sinus syndrome, vasovagal syncope, structural cardiac abnormalities, cardiac arrhythmias and conduction abnormalities. As stated in the recently published World Falls Guidelines, syncope in older adults often presents as falls, which is either due to amnesia for loss of consciousness, or pre-syncope leading to a fall, especially in those prone to falls with several other risk-factors for falls present. This difference in presentation can hinder the recognition of syncope. In patients with unexplained falls, or in whom the history comprises red flags for potential syncope, special attention to (pre)syncope is therefore warranted. When syncope is mistaken for other causes of a transient loss of consciousness, such as epileptic seizures, or when syncope presents as falls, patients are often referred to multiple specialists, which may in turn lead to excessive and unnecessary diagnostic testing and costs. Specialist services that are able to provide a comprehensive assessment can improve diagnostic yield and minimise diagnostic testing, thus improving patient satisfaction. Comprehensive assessment also leads to reduced length of hospital stay. Increasingly, geriatricians are involved in the assessment of syncope in the older patient, especially given the overlap with falls. Therefore, awareness of causes of syncope, as well as state-of-the-art assessment and treatment, is of great importance.
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Affiliation(s)
- Sofie Jansen
- Internal Medicine, Section of Geriatric Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Amsterdam Public Health, Aging and Later Life, Amsterdam, The Netherlands
| | - Nathalie van der Velde
- Internal Medicine, Section of Geriatric Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Amsterdam Public Health, Aging and Later Life, Amsterdam, The Netherlands
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Akbarpoor F, Alshehhi A, Aakef K, Ahmed A. A Rare Presentation of a Branchial Cleft Cyst: Can It Cause Syncope in a Pediatric Patient? Cureus 2023; 15:e50004. [PMID: 38186423 PMCID: PMC10766878 DOI: 10.7759/cureus.50004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2023] [Indexed: 01/09/2024] Open
Abstract
Branchial cleft cysts (BCCs) are a congenital malformation most commonly seen in children and adolescents. BCCs are usually incidental findings and are benign in nature. In this report, we present a case of a 13-year-old female with syncope as a rare complication of a fluid-filled second BCC. The patient initially presented with a unilateral non-tender swelling on the right side of the neck and submandibular region, which was suspicious of an inflammatory process. After initial lab investigations came back negative, imaging studies of the neck with computed tomography (CT) with intravenous contrast revealed a hypodense lesion with a uniform density, which lay beneath the sternocleidomastoid muscle and abutted the carotid sheath. The cyst was surgically excised, and histopathological studies of the cyst wall and the analysis of the fluid contained within the cyst confirmed that it was indeed a branchial cleft cyst. We propose that the syncopal episodes she experienced most likely occurred due to the proximity of the cyst wall to the carotid sheath, which caused a mass effect leading to carotid sinus syndrome (CSS). This is the first case of CSS due to a BCC to be reported in the pediatric population.
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Affiliation(s)
- Fatemeh Akbarpoor
- Medical School, College of Medicine, Mohammed Bin Rashid University Of Medicine and Health Sciences, Dubai, ARE
| | - Asma Alshehhi
- Medical School, College of Medicine, Mohammed Bin Rashid University Of Medicine and Health Sciences, Dubai, ARE
| | - Khadeeja Aakef
- Medical School, College of Medicine, Mohammed Bin Rashid University Of Medicine and Health Sciences, Dubai, ARE
| | - Aftab Ahmed
- Pediatric Surgery, Mediclinic Welcare Hospital, Dubai, ARE
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Baskovski E, Ates B, Altin T, Akyurek O. Cardioneuroablation for carotid sinus syndrome mediated by complete atrioventricular block. J Arrhythm 2023; 39:810-812. [PMID: 37799800 PMCID: PMC10549819 DOI: 10.1002/joa3.12915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 07/26/2023] [Accepted: 08/14/2023] [Indexed: 10/07/2023] Open
Abstract
Carotid sinus syndrome (CSS) is a rare condition leading to recurrent syncope. Permanent pacemaker implantation is the mainstay treatment of cardioinhibitory CSS. In this report, we present a CSS patient with reproducible atrioventricular block during carotid massage, who was treated with cardioneuroablation.
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Affiliation(s)
- Emir Baskovski
- Department of Cardiology, Faculty of MedicineAnkara UniversityMamakAnkaraTurkey
| | - Bilge Ates
- Department of Cardiology, Faculty of MedicineAnkara UniversityMamakAnkaraTurkey
| | - Timucin Altin
- Department of Cardiology, Faculty of MedicineAnkara UniversityMamakAnkaraTurkey
| | - Omer Akyurek
- Department of Cardiology, Faculty of MedicineAnkara UniversityMamakAnkaraTurkey
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Bozyel S, Güler TE, Çelik M, Dalgıç N, Şipal A, Yalnız A, Çağdaş M, Aksu T. Cardioneuroablation for treatment of carotid sinus syndrome secondary to orofarengeal squamoz cell cancer. J Cardiovasc Electrophysiol 2023; 34:1305-1309. [PMID: 36950851 DOI: 10.1111/jce.15895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 02/27/2023] [Accepted: 03/20/2023] [Indexed: 03/24/2023]
Abstract
INTRODUCTION Cardioneuroablation may be an alternative to pacing therapy to treat carotid sinus syndrome secondary to inoperable head and neck tumors. METHODS We performed, bi-atrial electroanatomic-mapping-guided (a fractionated electrogram-based) cardioneuroablation treatment. RESULTS Ablation procedure led to an increase in resting sinus heart rhythm (from 54 to 81 bpm). During the follow-up period of approximately 6 months, neither any bradycardia episodes (sinus bradycardia, sinus pause, AV block, etc.) nor any symptoms were observed in the patient. CONCLUSION In this case, we performed successful cardioneuroablation therapy for the first time in a patient with carotid sinus syndrome secondary to oropharyngeal squamous cell carcinoma. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Serdar Bozyel
- Health Sciences University, Derince Training and Research Hospital, Kocaeli, Turkey
| | - Tümer Erdem Güler
- Health Sciences University, Derince Training and Research Hospital, Kocaeli, Turkey
| | - Muhsin Çelik
- Health Sciences University, Derince Training and Research Hospital, Kocaeli, Turkey
| | - Nur Dalgıç
- Health Sciences University, Derince Training and Research Hospital, Kocaeli, Turkey
| | - Abdülcebbar Şipal
- Health Sciences University, Derince Training and Research Hospital, Kocaeli, Turkey
| | - Ahmet Yalnız
- Kocaeli University Faculty of Medicine, Department of Radiology, Kocaeli, Turkey
| | | | - Tolga Aksu
- Yeditepe University Medicine Faculty, İstanbul, Turkey
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Abstract
INTRODUCTION Treatment efficacy of reflex syncope is mainly related to the mechanism underlying syncope rather than its etiology or clinical presentation. The predominant mechanism underlying reflex syncope can be assigned to hypotensive or to bradycardic phenotypes. AREAS COVERED Methodology and diagnostic criteria of the most useful tests for the identification of hypotensive and bradycardic phenotypes are discussed. Diagnostic tests for the hypotensive phenotype include office blood pressure measurement with active standing test, home, and wearable blood pressure monitoring, 24-h ambulatory blood pressure monitoring and tilt table test. Diagnostic tests for the bradycardic phenotype include carotid sinus massage, tilt table test and prolonged ECG monitoring. EXPERT OPINION In reflex syncope, the documentation of bradycardia/asystole during a syncopal episode does not rule out the possibility that a preceding or parallel hypotensive reflex plays an important role. Similarly, even when a hypotensive mechanism is established, the possibility of an associated cardioinhibitory reflex should be investigated. Investigating the mechanism of reflex syncope is mandatory in patients with severe recurrent episodes, with the final aim to develop a personalized treatment strategy. Recent trials have demonstrated the benefits of personalized mechanism-based therapy, thus highlighting the importance of a comprehensive assessment of the mechanisms underlying syncope.
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Affiliation(s)
- Michele Brignole
- Department of Cardiology, S. Luca Hospital, IRCCS, Istituto Auxologico Italiano, Milan, Italy
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, and Department of Medicine, Karolinska Institute, Sweden
| | - Marcus Ståhlberg
- Department of Cardiology, Karolinska University Hospital, and Department of Medicine, Karolinska Institute, Sweden
| | - Antonella Groppelli
- Department of Cardiology, S. Luca Hospital, IRCCS, Istituto Auxologico Italiano, Milan, Italy
| | - Andrea Ungar
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
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Alagiakrishnan K. How can we better manage hypotensive syndromes in older adults? Expert Rev Cardiovasc Ther 2022; 20:503-505. [PMID: 35768910 DOI: 10.1080/14779072.2022.2094367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Voboril GR, Rotondaro JC, Rosati M, Cortés Guerrieri V, Martinez YP, Martinenghi N, Ludueña AV. [ Carotid sinus syndrome associated to cervical B-cell lymphoma]. Medicina (B Aires) 2022; 82:300-303. [PMID: 35417396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023] Open
Abstract
We present the case of a 75-year-old male with history of 5 months of right submaxillary tumor, with no clear etiology, who consulted for episodes of syncope preceded by dyspnea and sudden onset of profuse sweating. During his stay at the hospital, electrocardiographic records showed more than 3-second-long pauses after head movements, with a sensation of imminent loss of consciousness associated. A temporary pacemaker was required. Biopsy showed a diffuse non-germinal large B-cell B lymphoma, which required chemotherapy. After the first chemotherapy session, a significant reduction of the tumoral mass was observed, with abolition of the symptoms associated to cervical movements. The definitive diagnosis was malignant carotid sinus syndrome associated with cervical lymphoma.
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Affiliation(s)
- Gonzalo R Voboril
- Servicio de Clínica Médica, Instituto de investigaciones Médicas Alfredo Lanari, Buenos Aires, Argentina. E-mail:
| | - Julio C Rotondaro
- Servicio de Clínica Médica, Instituto de investigaciones Médicas Alfredo Lanari, Buenos Aires, Argentina
| | - Macarena Rosati
- Servicio de Clínica Médica, Instituto de investigaciones Médicas Alfredo Lanari, Buenos Aires, Argentina
| | - Verónica Cortés Guerrieri
- Servicio de Hematología, Instituto de investigaciones Médicas Alfredo Lanari, Buenos Aires, Argentina
| | - Yuly P Martinez
- Servicio de Hematología, Instituto de investigaciones Médicas Alfredo Lanari, Buenos Aires, Argentina
| | - Nicolás Martinenghi
- Servicio de Cardiología, Instituto de investigaciones Médicas Alfredo Lanari, Buenos Aires, Argentina
| | - Ana V Ludueña
- Servicio de Clínica Médica, Instituto de investigaciones Médicas Alfredo Lanari, Buenos Aires, Argentina
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Ando Y, Hashimoto K, Sano A, Fujita N, Yanagawa R, Ono Y, Obuchi Y, Tatsushima D, Watanabe S, Tomifuji M, Tanaka Y. Frequent occurrence of postbreakfast syncope due to carotid sinus syndrome after surgery for hypopharyngeal cancer: A case report. Medicine (Baltimore) 2021; 100:e25959. [PMID: 34011078 PMCID: PMC8137094 DOI: 10.1097/md.0000000000025959] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 04/28/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Syncope often occurs in patients with advanced head and neck cancers due to the stimulation of the autonomic nervous system by the tumor. Here, we describe a case of frequent syncopal episodes after laryngopharyngectomy for hypopharyngeal cancer. As all syncopal episodes were observed during the forenoon, we also evaluated the heart rate variability using ambulatory electrocardiography to determine why the syncopal episodes occurred during a specified period of the day. PATIENT CONCERNS A 73-year-old Japanese man who underwent laryngopharyngectomy for recurrent hypopharyngeal cancer started experiencing frequent episodes of loss of consciousness that occurred during the same time period (10:00-12:00). He had never experienced syncopal episodes before the operation. From 23 to 41 days postoperatively, he experienced 9 syncopal episodes that occurred regardless of his posture. DIAGNOSES Pharyngo-esophagoscopy revealed an anastomotic stricture between the free jejunum graft and the upper esophagus. Swallowing videofluoroscopy confirmed the dilatation of the jejunal autograft and a foreign body stuck on the oral side of the anastomosis. Contrast-enhanced computed tomography revealed that the carotid artery was slightly compressed by the edematous free jejunum. The patient was diagnosed with carotid sinus syndrome (CSS) as the free jejunum was dilated when consuming breakfast, which may have caused carotid sinus hypersensitivity and induced a medullary reflex. INTERVENTIONS Administration of disopyramide was effective in preventing syncope. Heart rate variability analysis using ambulatory electrocardiography showed that parasympathetic dominancy shifted to sympathetic dominancy during 10:00 to 12:00. The significant time regularity of the syncopal episodes may have been affected by modified diurnal variation in autonomic tone activity. OUTCOMES After the surgical release and re-anastomosis of the pharyngoesophageal stenosis via an open-neck approach, no recurrent episodes of syncope were reported. LESSONS We reported a case of frequent syncopal episodes limited to the forenoon due to CSS after surgery for hypopharyngeal carcinoma. The patient was treated with anticholinergics followed by the release and re-anastomosis of the pharyngoesophageal stenosis. When syncope occurs after surgery for head and neck lesions, CSS due to postoperative structural changes should be considered as a differential diagnosis of syncope.
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Affiliation(s)
- Yuya Ando
- Department of General Medicine, National Defense Medical College, Tokorozawa, Saitama
- Department of Family Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo
| | - Kenichi Hashimoto
- Department of General Medicine, National Defense Medical College, Tokorozawa, Saitama
| | - Azusa Sano
- Department of General Medicine, National Defense Medical College, Tokorozawa, Saitama
| | - Naoya Fujita
- Department of General Medicine, National Defense Medical College, Tokorozawa, Saitama
| | - Rempei Yanagawa
- Department of General Medicine, National Defense Medical College, Tokorozawa, Saitama
| | - Yosuke Ono
- Department of General Medicine, National Defense Medical College, Tokorozawa, Saitama
| | - Yasuhiro Obuchi
- Department of General Medicine, National Defense Medical College, Tokorozawa, Saitama
| | - Daisuke Tatsushima
- Department of Otolaryngology, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Shun Watanabe
- Department of Otolaryngology, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Masayuki Tomifuji
- Department of Otolaryngology, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Yuji Tanaka
- Department of General Medicine, National Defense Medical College, Tokorozawa, Saitama
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Brignole M, Croci F, Solano A, Donateo P, Maggi R, Solari D, Bertolone C, Fontana D, Oddone D. Reproducibility of carotid sinus massage. Pacing Clin Electrophysiol 2020; 43:1190-1193. [PMID: 32364652 DOI: 10.1111/pace.13934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 04/27/2020] [Indexed: 11/29/2022]
Abstract
AIMS The reproducibility of carotid sinus massage (CSM) is debated. The aim of this study was to assess the reproducibility according to the methodology and diagnostic criteria defined by the guidelines on syncope of the European Society of Cardiology. METHOD Among 2800 patients with syncope who underwent CSM in the years 2005-2019, 109 patients (62 males; mean age 76 ± 10 years) had performed a second CSM after a median of 28 months. Carotid sinus hypersensitivity (CSH) was diagnosed when CSM elicited a pause of >3 s and/or a fall in systolic blood pressure >50 mm Hg without reproduction of spontaneous symptoms. Carotid sinus syndrome (CSS) was established when spontaneous symptoms were reproduced in the presence of bradycardia and/or hypotension. RESULTS The reproducibility of CSM was 78% for 18 CSS patients, 41% for 29 CSH patients, and 77% for 62 negative patients. The corresponding interrater agreement was good for CSS (kappa = 0.66), moderate for negative CSM (kappa = 0.42), and poor for CSH (kappa = 0.30). Combining CSH and negative tests, their reproducibility rose to 90% with kappa = 0.66. CONCLUSION CSS but not CSH has a good reproducibility. About half of patients with CSH had a negative response at the second test, thus suggesting a great overlap between them.
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Affiliation(s)
- Michele Brignole
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, Lavagna, Italy.,IRCCS Istituto Auxologico Italiano, Faint & Fall Programme, Ospedale San Luca, Milano, Italy
| | - Francesco Croci
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, Lavagna, Italy
| | - Alberto Solano
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, Lavagna, Italy
| | - Paolo Donateo
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, Lavagna, Italy
| | - Roberto Maggi
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, Lavagna, Italy
| | - Diana Solari
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, Lavagna, Italy
| | - Cristina Bertolone
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, Lavagna, Italy
| | - Daniele Fontana
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, Lavagna, Italy
| | - Daniele Oddone
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, Lavagna, Italy
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Fang C, Yang L, Zeng G, Huang R, Fang W, Chen Y, Guan J, Li P, Huang X, Lin L. Treatment of syncope in tongue cancer with palliative chemotherapy in the intensive care unit: A case report. Medicine (Baltimore) 2019; 98:e16998. [PMID: 31464952 PMCID: PMC6736034 DOI: 10.1097/md.0000000000016998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Syncope caused by head and neck cancer (HNC) is rare. However, syncope caused by tongue cancer (TC) is even rarer. In TC, syncope is caused by tumor-mediated compression of the carotid sinus and stimulation of the glossopharyngeal nerve. PATIENT CONCERNS In this study, we report the case of a 48-year-old male patient who was diagnosed with advanced TC and bilateral cervical lymph node metastasis. On the third day of admission, the patient experienced recurrent syncope with hypotension and bradycardia. DIAGNOSES The patient was diagnosed with a well-differentiated squamous cell carcinoma of the tongue along with massive cervical lymph node metastasis and carotid sinus syndrome. INTERVENTIONS Initially, symptomatic treatment of syncope boosted the blood pressure and increased the heart rate. Thereafter, a temporary pacemaker was implanted. Finally, chemotherapy was used to control the tumor and relieve syncope. OUTCOMES After chemotherapy, the tongue ulcers and cervical lymph node reduced in size; syncope did not recur. LESSONS This case shows that chemotherapy may be a valid treatment option in patients with cancer-related syncope; however, the choice of chemotherapeutic drugs is critical. Intensive care provides life support to patients and creates opportunities for further treatment.
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Affiliation(s)
- Chongkai Fang
- First Clinical Medical College, Guangzhou University of Chinese Medicine
| | - Liting Yang
- First Clinical Medical College, Guangzhou University of Chinese Medicine
| | - Guangbi Zeng
- First Clinical Medical College, Guangzhou University of Chinese Medicine
| | - Ruilin Huang
- First Clinical Medical College, Guangzhou University of Chinese Medicine
| | - Wei Fang
- Department of Oral and Maxillofacial Surgery, Stomatological Hospital, Southern Medical University
| | - Yao Chen
- Cancer center, First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jieshan Guan
- Cancer center, First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Peng Li
- Cancer center, First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xuewu Huang
- Cancer center, First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Lizhu Lin
- Cancer center, First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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Zhao Z, Pan S, Yan N, Wang D, Li Z. Severe bradycardia caused by the deviation of the laryngeal mask airway Supreme: A case report. Medicine (Baltimore) 2019; 98:e15904. [PMID: 31192924 PMCID: PMC6587568 DOI: 10.1097/md.0000000000015904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
RATIONALE Classic laryngeal mask airway (LMA) has long been used for airway management. The LMA Supreme is a modified single-use version of the LMA Proseal, but it still remains some deficits such as the instable positioning that lead to easily sliding and the mask bowl full of air might lead to the reduced blood flow of the internal carotid artery. The carotid sinus is a baroreceptor that responds to the stretching of the arterial wall. Manual pressure of the carotid artery at the upper margin of the sternocleidomastoid muscle provoked bradycardia and hypotension. PATIENT CONCERNS A previously fit and well 42-year-old woman presented with breast fibroma on the left side. No other disease history could be recorded. Her family history was negative for neuromuscular and autoimmune disease. DIAGNOSES The patient suffered from a severe bradycardia and hypotension when the LMA showed a shift. We presented with a hypothetical that the dislocated LMA may cause carotid sinus syndrome (CSS). INTERVENTIONS The patient's heart rate (HR) gradually rosed up as soon as the LMA adjusted back to the normal position. OUTCOMES The patient was comfortable in the post anesthesia care unit (PACU) and had no adverse sequelae. LESSONS The position of LMA Supreme should be confirmed throughout the surgery especially for the ones who has changed the position and the head was covered by surgical drapes.
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Golovina GA, Duplyakov DV. [Key Points of the 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope]. Kardiologiia 2018:89-100. [PMID: 30131047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The article presents key points of published in March 2017, Guideline for the Evaluation and Management of Patients With Syncope (A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society). This document contains summary and analysis of evidence base and accumulated experience in this field and reflect further development of the problem of the management of adult and pediatric patients with suspected syncope. Traditionally, the basis of diagnostic algorithm of these patients has been primary examination, and in the present guideline one can find strengthening of the importance of anamnestic criteria, and supplementation of ECG criteria of arrhythmic syncope. At the same time, the diagnostic value of provocative tests has been revised, and the class of indications for these tests has been lowered. According to the guideline, along with diagnosis of the cause of fainting, risk stratifcation of short- and long-term adverse outcomes has a key value. The guideline summarizes latest achievements in the treatment of fainting in sarcoidosis, arrhythmogenic right ventricular dysplasia, primary arrhythmic heart diseases, orthostatic hypotension, and reflex-mediated syncope. Despite orientation on specifc properties of medical care in the USA, the guideline can be useful to practical physicians in choice of the best strategy of diagnosis and treatment of syncope in each individual case.
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Porzionato A, Macchi V, Stecco C, De Caro R. The Carotid Sinus Nerve-Structure, Function, and Clinical Implications. Anat Rec (Hoboken) 2018; 302:575-587. [PMID: 29663677 DOI: 10.1002/ar.23829] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 06/24/2017] [Accepted: 08/01/2017] [Indexed: 12/12/2022]
Abstract
Interest has been renewed in the anatomy and physiology of the carotid sinus nerve (CSN) and its targets (carotid sinus and carotid body, CB), due to recent proposals of surgical procedures for a series of common pathologies, such as carotid sinus syndrome, hypertension, heart failure, and insulin resistance. The CSN originates from the glossopharyngeal nerve soon after its appearance from the jugular foramen. It shows frequent communications with the sympathetic trunk (usually at the level of the superior cervical ganglion) and the vagal nerve (main trunk, pharyngeal branches, or superior laryngeal nerve). It courses on the anterior aspect of the internal carotid artery to reach the carotid sinus, CB, and/or intercarotid plexus. In the carotid sinus, type I (dynamic) carotid baroreceptors have larger myelinated A-fibers; type II (tonic) baroreceptors show smaller A- and unmyelinated C-fibers. In the CB, afferent fibers are mainly stimulated by acetylcholine and ATP, released by type I cells. The neurons are located in the petrosal ganglion, and centripetal fibers project on to the solitary tract nucleus: chemosensory inputs to the commissural subnucleus, and baroreceptor inputs to the commissural, medial, dorsomedial, and dorsolateral subnuclei. The baroreceptor component of the CSN elicits sympatho-inhibition and the chemoreceptor component stimulates sympatho-activation. Thus, in refractory hypertension and heart failure (characterized by increased sympathetic activity), baroreceptor electrical stimulation, and CB removal have been proposed. Instead, denervation of the carotid sinus has been proposed for the "carotid sinus syndrome." Anat Rec, 302:575-587, 2019. © 2018 Wiley Periodicals, Inc.
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Affiliation(s)
- Andrea Porzionato
- Department of Neuroscience, Institute of Human Anatomy, University of Padova, Padova, Italy
| | - Veronica Macchi
- Department of Neuroscience, Institute of Human Anatomy, University of Padova, Padova, Italy
| | - Carla Stecco
- Department of Neuroscience, Institute of Human Anatomy, University of Padova, Padova, Italy
| | - Raffaele De Caro
- Department of Neuroscience, Institute of Human Anatomy, University of Padova, Padova, Italy
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Finucane C, Colgan MP, O'Dwyer C, Fahy C, Collins O, Boyle G, Kenny RA. The accuracy of anatomical landmarks for locating the carotid sinus. Age Ageing 2016; 45:904-907. [PMID: 27496933 DOI: 10.1093/ageing/afw105] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 04/21/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND carotid sinus massage (CSM) is a valuable clinical test for carotid sinus syndrome (CSS) and relies on accurately locating the carotid sinus (CS). OBJECTIVE in this study, we sought to examine the accuracy of using anatomical landmarks for locating the CS. METHODS consecutive patients (n = 20) were recruited prospectively. Two clinicians, trained in CSM, were asked to locate the CS using anatomical landmarks. A point on the skin overlying the CS was then marked by a vascular technician using ultrasound. Accuracy of techniques was compared using intra-class correlation coefficients and Bland-Altman statistics. RESULTS anatomical landmarks underestimated the CS location by 1.5 ± 1.3 cm. Error extremes ranged from 4 cm below to 2 cm above CS using anatomical landmarks. A moderate correlation between ultrasound and anatomical landmarks was found, r = 0.371 (P = 0.031). CONCLUSION this is the first study to characterise the accuracy of standard anatomical landmarks used in CSM. Results suggest that the point of maximal pulsation has the lowest associated error. Future work should examine CSM yield across this and a range of other methodological factors.
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Affiliation(s)
- Ciaran Finucane
- Mercer's Institute for Successful Ageing, St. James's Hospital, Dublin, Ireland
- Department of Medical Physics and Bioengineering, St. James's Hospital, Dublin, Ireland
| | - Mary Paula Colgan
- Department of Vascular and Endovascular Surgery, St. James's Hospital, Dublin, Ireland
| | - Clodagh O'Dwyer
- Department of Medical Gerontology, St. Vincent's Hospital, Dublin, Ireland
| | - Collette Fahy
- Department of Vascular and Endovascular Surgery, St. James's Hospital, Dublin, Ireland
| | - Orla Collins
- Department of Medical Gerontology, St. Vincent's Hospital, Dublin, Ireland
| | - Gerry Boyle
- Mercer's Institute for Successful Ageing, St. James's Hospital, Dublin, Ireland
- Department of Medical Physics and Bioengineering, St. James's Hospital, Dublin, Ireland
| | - Rose Anne Kenny
- Mercer's Institute for Successful Ageing, St. James's Hospital, Dublin, Ireland
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O'Callaghan S, Kenny RA. Neurocardiovascular Instability and Cognition. Yale J Biol Med 2016; 89:59-71. [PMID: 27505017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Neurocardiovascular instability (NCVI) refers to abnormal neural control of the cardiovascular system affecting blood pressure and heart rate behavior. Autonomic dysfunction and impaired cerebral autoregulation in aging contribute to this phenomenon characterized by hypotension and bradyarrhythmia. Ultimately, this increases the risk of falls and syncope in older people. NCVI is common in patients with neurodegenerative disorders including dementia. This review discusses the various syndromes that characterize NCVI icluding hypotension, carotid sinus hypersensitivity, postprandial hypotension and vasovagal syncope and how they may contribute to the aetiology of cognitive decline. Conversely, they may also be a consequence of a common neurodegenerative process. Regardless, recognition of their association is paramount in optimizing management of these patients.
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Abstract
Syncope in a pacemaker patient is a serious symptom but it is rarely due a pacemaker system malfunction. Syncope occurs in about 5 % of patients paced for atrioventricular (AV) block in 5 years, 18% in those paced for sinus node disease in 10 years, 20 % of those paced for carotid sinus syndrome in 5 years and 5-55 % of those older patients paced for vasovagal syncope in 2 years. The vastly different results in vasovagal syncope depend on the results of tilt testing, where those with negative tests approach results in pacing for AV block and those with a positive tilt test show no better results than with no pacemaker. The implication of tilt results is that a hypotensive tendency is clearly demonstrated by tilt positivity pointing to syncope recurrence with hypotension. This problem may be addressed by treatment with vasoconstrictor drugs in those who are suited or, more commonly, a reduction or cessation of hypotensive therapy in hypertensive patients. Other causes of syncope such as tachyarrhythmias are rare. The clinical approach to patients who report syncope is detailed.
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Affiliation(s)
- Richard Sutton
- National Heart & Lung Institute, Imperial College, London, UK
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Georgakopoulos J, Katsilieris J, Papaloucas C, Kelekis N, Kouloulias V. Carotid sinus malfunction presenting with presyncopal episodes during radiation therapy for head and neck cancer. JRSM Open 2014; 5:2054270414527937. [PMID: 25057400 PMCID: PMC4100225 DOI: 10.1177/2054270414527937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We report the case of a 67-year-old Caucasian man with unexplained presyncopal episodes during radiation therapy for oropharyngeal cancer.
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Affiliation(s)
- John Georgakopoulos
- Radiation Oncology Unit, 2nd Department Radiology, Radiotherapy Unit, Attikon University Hospital, Rimini 1, Chaidari 12462, Athens, Greece
| | - John Katsilieris
- 3rd Radiotherapy Department, Agios Savvas Hospital, 11522, Athens, Greece
| | - Christos Papaloucas
- Anatomy Department, Medical School, Thrace University, 69100, Alexandroupolis, Greece
| | - Nikolaos Kelekis
- Radiation Oncology Unit, 2nd Department Radiology, Radiotherapy Unit, Attikon University Hospital, Rimini 1, Chaidari 12462, Athens, Greece
| | - Vassilis Kouloulias
- Radiation Oncology Unit, 2nd Department Radiology, Radiotherapy Unit, Attikon University Hospital, Rimini 1, Chaidari 12462, Athens, Greece
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Abstract
Carotid sinus syndrome (CSS) is a disease of the autonomic nervous system presenting with syncope, especially in older males who often have cardiovascular disease. The aetiology is unknown and epidemiological data is limited. Forty new patients/million population have been estimated to require pacing for CSS and these patients represent ∼9% of those presenting syncope to a specialist facility. CSS is defined as a response to carotid sinus massage (CSM) that includes reproduction of spontaneous symptoms. Cardioinhibitory CSS shows 3s asystole on CSM and vasodepressor CSS shows >50 mmHg fall in blood pressure (BP), there are mixed forms. The methodology of CSM requires correct massage in the supine and upright with continuous ECG and BP. Assessment of the vasodepressor component implies the ‘method of symptoms’ using atropine to prevent asystole. Carotid sinus hypersensitivity (CSH) is a related condition where CSM is positive in an asymptomatic patient. CSH cannot be assumed to respond to pacing. CSS patients present syncope with little or no warning. If no cause is revealed by the initial evaluation, CSM should be considered in all patients >40 years. CSM carries a small risk of thromboembolism. Therapy for cardioinhibitory CSS is dual chamber pacing, which is most effective in patients with a negative tilt test. Syncope recurrence is ∼20% in 5 years in paced patients. Therapy for the vasodepressor component of CSS, as pure vasodepression or mixed, where tilt testing will likely be positive, is often unrewarding: alternative therapeutic measures may be needed including discontinuation/reduction of hypotensive drugs.
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Affiliation(s)
- Richard Sutton
- Emeritus Professor of Clinical Cardiology, National Heart & Lung Institute, Imperial College, London, UK
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Abstract
A rapid change in ageing demographic is taking place worldwide such that healthcare professionals are increasingly treating old and very old patients. Syncope in the elderly is a challenging presentation that is under-recognised, particularly in the acute care setting. The reason for this is that presentation in the older person may be atypical: patients are less likely to have a prodrome, may have amnesia for loss of consciousness and events are frequently unwitnessed. The older patient thus may present with a fall rather than transient loss of consciousness. There is an increased susceptibility to syncope with advancing age attributed to age-related physiological impairments in heart rate and blood pressure, and alterations in cerebral blood flow. Multi-morbidity and polypharmacy in these complex patients increases susceptibility to syncope. Cardiac causes and more than one possible cause are also common. Syncope is a major cause of morbidity and mortality and is associated with enormous personal and wider health economic costs. In view of this, prompt assessment and early targeted intervention are recommended. The purpose of this article is to update the reader regarding the presentation and management of syncope in this rapidly changing demographic.
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Affiliation(s)
- Helen O' Brien
- Department of Medical Gerontology, TCIN, St James's Hospital, Dublin, Ireland
| | - Rose Anne Kenny
- Department of Medical Gerontology, TCIN, St James's Hospital, Dublin, Ireland
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