-
CNS Neuroscience & Therapeutics Feb 2024Scarce evidence is available to elucidate the association between the abnormal microstructure of white matter (WM) and cognitive performance in patients with orthostatic...
OBJECTIVE
Scarce evidence is available to elucidate the association between the abnormal microstructure of white matter (WM) and cognitive performance in patients with orthostatic hypotension (OH). This study investigated the microstructural integrity of WM in patients with mild OH (MOH) and severe OH (SOH) and evaluated the association of abnormal WM microstructure with the broad cognitive domains and cognition-related plasma biomarkers.
METHODS
Our study included 72 non-OH (NOH), 17 MOH, and 11 SOH participants. Across the groups, the WM integrity was analyzed by neurite orientation dispersion and density imaging (NODDI), and differences in WM microstructure were evaluated by nonparametric tests and post hoc models. The correlations between WM microstructure and broad cognitive domains and cognition-related plasma biomarkers were assessed by Spearman's correlation analysis.
RESULTS
The abnormal WM microstructure was localized to the WM fiber bundles in MOH patients but distributed widely in SOH cohorts (p < 0.05). Further analysis showed that the neurite density index of the left cingulate gyrus was negatively associated with amyloid β-40, glial fibrillary acidic protein, neurofilament light chain, phospho-tau181 (p < 0.05) but positively with global cognitive function (MOCA, MMSE, AER-III), memory, attention, language, language fluency, visuospatial function and amyloid β-40 / amyloid β-42 (p < 0.05). Additionally, other abnormal WM microstructures of OH were associated with broad cognitive domains and cognition-related plasma biomarkers to varying degrees.
CONCLUSION
The findings evidence that abnormal WM microstructures may present themselves as early as in the MOH phase and that these structural abnormalities are associated with cognitive functions and cognition-related plasma biomarkers.
Topics: Humans; White Matter; Amyloid beta-Peptides; Neurites; Hypotension, Orthostatic; Diffusion Tensor Imaging; Biomarkers; Brain
PubMed: 38421091
DOI: 10.1111/cns.14586 -
European Heart Journal. Case Reports Feb 2024Primary autonomic failure (PAF) or Bradbury Eggleston syndrome is a neurodegenerative disorder of the autonomic nervous system characterized by orthostatic hypotension.
BACKGROUND
Primary autonomic failure (PAF) or Bradbury Eggleston syndrome is a neurodegenerative disorder of the autonomic nervous system characterized by orthostatic hypotension.
CASE SUMMARY
We report the case of a 76-year-old patient with a history of hypertension, who presented with exercise-induced fatigue. He exhibited systolic hypertension and resting bradycardia in the supine position, with orthostatic hypotension without reactive tachycardia, suggesting dysautonomia. Neurological examination was unremarkable. The patient underwent cardiovascular autonomic testing, revealing evidence of beta-sympathetic deficiency associated with neurogenic orthostatic hypotension. Causes of secondary dysautonomia were excluded. The patient was diagnosed with PAF. Even if managing the combination of supine hypertension and orthostatic hypotension was challenging, significant improvements in functional and haemodynamic status were observed with a personalized management approach.
DISCUSSION
Throughout this case report, we emphasize the critical need for an evaluation of autonomic function and blood pressure's dynamics in hypertensive patients experiencing orthostatic symptoms, enabling the implementation of tailored therapeutic strategies.
PubMed: 38419751
DOI: 10.1093/ehjcr/ytae073 -
Journal of Neurology May 2024Microsurgical sealing of spinal cerebrospinal fluid (CSF) leaks is a viable treatment option in spontaneous intracranial hypotension (SIH). Several factors may influence...
OBJECTIVE
Microsurgical sealing of spinal cerebrospinal fluid (CSF) leaks is a viable treatment option in spontaneous intracranial hypotension (SIH). Several factors may influence the outcome, with symptom duration probably the most modifiable variable.
METHODS
Patients with closure of spinal CSF leaks between September 2020 and March 2023 and a follow-up period of 6 months were included in this retrospective single-center study. Pre- and postoperative scores for impact of headaches (Headache Impact Test, HIT-6) and quality of life (QoL, EQ-5D-5L) were systematically collected. Multiple regression modelling and subgroup analyses for different symptom durations and comorbidities were performed for these outcomes.
RESULTS
One hundred patients (61% female, median age 43.5 years) were included. Six months postoperatively, there was significant improvement in headache impact (HIT-6: 66 (IQR 62-69) to 52 (IQR 40-61, p < 0.001) and QoL (EQ-5D-5L VAS: 40 (IQR 30-60) to 79 (IQR 60-90); EQ-5D-5L Index: 0.67 (IQR 0.35-0.8) to 0.91 (IQR 0.8-0.94, p < 0.001, respectively). Subgroup analysis for a symptom duration above (74%) and below 90 days (26%) and comorbidity, as well as multiple regression analysis, revealed a trend in favor of early treatment and lower comorbidity. However, even after a prolonged symptom duration, improvements were significant.
CONCLUSION
As patients with shorter symptom duration show a trend for a better outcome, our results promote a timely diagnosis and treatment in SIH patients. However, a significant postoperative improvement can still be expected even after a prolonged symptom duration.
Topics: Humans; Female; Male; Adult; Middle Aged; Cerebrospinal Fluid Leak; Retrospective Studies; Quality of Life; Comorbidity; Intracranial Hypotension; Time Factors; Treatment Outcome; Follow-Up Studies; Microsurgery; Neurosurgical Procedures; Headache
PubMed: 38409537
DOI: 10.1007/s00415-024-12242-2 -
Research Square Feb 2024Neurogenic orthostatic hypotension (nOH) is a frequent non-motor feature of Parkinson's disease (PD), associated with adverse outcomes. Recently, 24-hour ambulatory BP...
PURPOSE
Neurogenic orthostatic hypotension (nOH) is a frequent non-motor feature of Parkinson's disease (PD), associated with adverse outcomes. Recently, 24-hour ambulatory BP monitoring (ABPM) has been shown to diagnose nOH with good accuracy (in the presence of at least 2 episodes of systolic BP drop ≥ 15 mmHg compared to the average 24-h). This study aims at evaluating the prognostic role of ABPM-hypotensive episodes in predicting PD disability milestones and mortality and comparing it to well-defined prognostic role of nOH.
METHODS
PD patients who underwent ABPM from January 2012 to December 2014 were retrospectively enrolled and assessed for the development of falls, fractures, dementia, bed/wheelchair confinement, hospitalization, mortality, during an up-to-10-year follow-up.
RESULTS
Ninety-nine patients (male 74%; age: 64.0 ± 10.1 years; PD duration: 6.4 ± 4.0 years) were enrolled. At baseline, 38.4% of patients had ABPM-hypotensive episodes and 46.5% had bedside nOH.At Kaplan-Meier analysis patients with ABPM-hypotensive episodes had an earlier onset of falls (p = 0.001), fractures (p = 0.004), hospitalizations (p = 0.009), bed/wheelchair confinement (p = 0.032), dementia (p = 0.001), and showed a shorter survival (8.0vs9.5 years; p = 0.009). At Cox regression analysis (adjusted for age, disease duration, Charlson Comorbidity Index, and H&Y stage at baseline) a significant association was confirmed between ABPM-hypotensive episodes and falls (OR:3.626; p = 0.001), hospitalizations (OR:2.016; p = 0.038), and dementia (OR:2.926; p = 0.008), while bedside nOH was only associated with falls (OR 2.022; p = 0.039) and dementia (OR:1.908; p = 0.048).
CONCLUSION
The presence of at least two ABPM-hypotensive episodes independently predicted the development of falls, dementia, and hospitalization, showing a stronger prognostic value than the simple bedside assessment.
PubMed: 38405860
DOI: 10.21203/rs.3.rs-3904996/v1 -
PloS One 2024Fear of orthostatic hypotension (OH) and a reported association with an increased risk of cardiovascular (CV) events may limit antihypertensive treatment after...
BACKGROUND
Fear of orthostatic hypotension (OH) and a reported association with an increased risk of cardiovascular (CV) events may limit antihypertensive treatment after stroke/TIA. In the NAILED trial, systematic titration of antihypertensive treatment resulted in lower blood pressure (BP) and reduced the incidence of stroke. Our aim was to assess the association between OH and CV events or death in a stroke/TIA population and the association between group allocation in the NAILED trial and risk of OH during follow-up.
METHODS AND FINDINGS
This post-hoc analysis included all patients with complete BP measurement at baseline in the NAILED trial (n = 814). OH was defined as a drop in systolic BP ≥20 or diastolic BP ≥10 mmHg 1 minute after standing from a seated position. The association between OH and a composite of stroke, myocardial infarction, or death was assessed using an adjusted Cox regression model with OH as a time-varying variable. The association between group allocation (intervention vs. control) and OH was assessed using logistic regression. During a mean follow-up of 4.8 years, 35.3% of patients had OH at some point. OH was not significantly associated with the composite outcome (HR: 1.11, 95% CI: 0.80-1.54). Allocation to the intervention group in the NAILED trial was not associated with OH during follow-up (OR: 0.84, 95% CI: 0.62-1.13).
CONCLUSIONS
OH was not associated with an increased risk of CV events or death in this stroke/TIA population. Systematic titration of antihypertensive treatment did not increase the prevalence of OH compared to usual care. Thus, OH did not reduce the gains of antihypertensive treatment.
Topics: Humans; Hypotension, Orthostatic; Ischemic Attack, Transient; Antihypertensive Agents; Stroke; Blood Pressure; Risk Factors; Hypertension
PubMed: 38394187
DOI: 10.1371/journal.pone.0298435 -
Neurologia I Neurochirurgia Polska 2024Low pressure of cerebrospinal fluid (CSF) is a rare cause of headache, except when the patient undergoes a lumbar puncture. Headache associated with a low CSF pressure... (Review)
Review
Low pressure of cerebrospinal fluid (CSF) is a rare cause of headache, except when the patient undergoes a lumbar puncture. Headache associated with a low CSF pressure i.e. intracranial hypotension causes diagnostic difficulties. Headaches related to spontaneous intracranial hypotension (SIH) pose a significant diagnostic challenge in everyday neurological practice. Patients with headaches due to SIH are usually diagnosed only after a long delay. Diagnostic problems may result in unnecessary invasive diagnostic procedures, or even neurosurgical operations. Diagnosing headaches attributed to SIH requires the consideration of several clinical scenarios, and the disease's features causing primary or secondary disturbances. In this review, we discuss the differential diagnosis of SIH-related headaches with reference to accumulated knowledge, including meta-analyses, guidelines, casuistry, and the applicable criteria of the International Classification of Headache Disorders. In addition, we discuss head and spine magnetic resonance imaging abnormalities, which may indicate intracranial hypotension.
Topics: Humans; Intracranial Hypotension; Headache; Magnetic Resonance Imaging; Diagnosis, Differential
PubMed: 38393961
DOI: 10.5603/pjnns.97407 -
Journal of Medical Case Reports Feb 2024Cardiac autonomic neuropathy is a highly prevalent pathology in the diabetic population, and is the leading cause of death in this population. Orthostatic hypotension is...
BACKGROUND
Cardiac autonomic neuropathy is a highly prevalent pathology in the diabetic population, and is the leading cause of death in this population. Orthostatic hypotension is the main clinical manifestation of the disease. In some patients, this orthostatic hypotension is associated with supine hypertension, posing a therapeutic challenge since treatment of one entity may aggravate the other. The challenge is to manage each of these two hemodynamic opposites without exposing the patient to a life-threatening risk of severe hypotension or hypertension.
CASE PRESENTATION
We report a case of a 62-year-old ethnic Moroccan woman who has cardiovascular risk factors such as type 2 diabetes, arterial hypertension, and dyslipidemia. The patient's symptoms included dizziness, tremors, morning sickness, palpitations, and intolerance to exertion. Given her symptomatology, the patient benefited from an exploration of the autonomic nervous system through cardiovascular reactivity tests (Ewing tests), which confirmed the diagnosis of cardiac autonomic neuropathy. In addition to orthostatic hypotension, our patient had supine arterial hypertension, complicating management. To treat orthostatic hypotension, we advised the patient to avoid the supine position during the day, to raise the head of the bed during the night, and to have a sufficient fluid intake, with a gradual transition from decubitus to orthostatism and venous restraint of the lower limbs. Supine hypertension was treated with transdermal nitrates placed at bedtime and removed 1 hour before getting up. One week after the introduction of treatment, the patient reported a clear regression of functional symptoms, with an improvement in her quality of life. Improvement in symptomatology was maintained during quarterly follow-up consultations.
CONCLUSIONS
Cardiac autonomic neuropathy is a very common pathology in diabetic patients. It is a serious condition with a life-threatening prognosis. Its management must be individualized according to the symptomatology and profile of each patient. The treatment of patients with orthostatic hypotension and supine hypertension requires special attention to ensure that each entity is treated without aggravating the other.
Topics: Female; Humans; Middle Aged; Hypotension, Orthostatic; Diabetes Mellitus, Type 2; Quality of Life; Hypertension; Autonomic Nervous System Diseases; Autonomic Nervous System
PubMed: 38374205
DOI: 10.1186/s13256-024-04346-0 -
Cureus Jan 2024Catatonia, which is associated with gamma-aminobutyric acid (GABA) hypoactivity, often responds robustly to benzodiazepines. It has been reported to be a consequence of...
Catatonia, which is associated with gamma-aminobutyric acid (GABA) hypoactivity, often responds robustly to benzodiazepines. It has been reported to be a consequence of abrupt discontinuation of clozapine, an antipsychotic used for treatment-resistant schizophrenia. Clozapine discontinuation, sometimes necessitated by medical concerns, can carry the risk of adverse outcomes, including catatonia. We present the case of a 66-year-old African-American male with schizoaffective disorder (depressive subtype) and a complex medical history. He discontinued clozapine abruptly due to medication unavailability, and, seven days later, presented with catatonic symptoms, initially unrecognized by emergency room clinicians. His symptoms included self-neglect, auditory hallucinations, isolation, psychomotor retardation, fixed gaze, and thought blocking. An attempt to reinstate clozapine led to orthostatic hypotension, prompting admission to an inpatient psychiatry unit. Attempt to initiate risperidone for psychosis worsened the catatonia, which then responded rapidly to intravenous lorazepam challenge. This facilitated the re-introduction of clozapine with slow re-titration.
PubMed: 38370988
DOI: 10.7759/cureus.52462 -
Journal of the Korean Society of... Jan 2024Spontaneous intracranial hypotension (SIH), which generally presents as orthostatic headache, is increasingly being identified due to improved imaging technologies and... (Review)
Review
Spontaneous intracranial hypotension (SIH), which generally presents as orthostatic headache, is increasingly being identified due to improved imaging technologies and heightened awareness. Many prior studies have reported the characteristic brain MRI findings of SIH. However, recently, focus has shifted to spinal MRI, as SIH is believed to be caused by leakage of cerebrospinal fluid from the spinal dural sac. Advanced techniques such as ultrafast CT myelography and digital subtraction myelography have emerged as useful technique to identify the site of cerebrospinal fluid leakage. In this review, we discuss the diagnosis, spinal MRI findings, imaging techniques, and treatment of SIH.
PubMed: 38362391
DOI: 10.3348/jksr.2023.0151 -
Journal of Clinical Medicine Jan 2024Syncope is a highly prevalent clinical condition characterized by a rapid, complete, and brief loss of consciousness, followed by full recovery caused by cerebral... (Review)
Review
Syncope is a highly prevalent clinical condition characterized by a rapid, complete, and brief loss of consciousness, followed by full recovery caused by cerebral hypoperfusion. This symptom carries significance, as its potential underlying causes may involve the heart, blood pressure, or brain, leading to a spectrum of consequences, from sudden death to compromised quality of life. Various factors contribute to syncope, and adhering to a precise diagnostic pathway can enhance diagnostic accuracy and treatment effectiveness. A standardized initial assessment, risk stratification, and appropriate test identification facilitate determining the underlying cause in the majority of cases. New technologies, including artificial intelligence and smart devices, may have the potential to reshape syncope management into a proactive, personalized, and data-centric model, ultimately enhancing patient outcomes and quality of life. This review addresses key aspects of syncope management, including pathogenesis, current diagnostic testing options, treatments, and considerations in the geriatric population.
PubMed: 38337421
DOI: 10.3390/jcm13030727