1/84. syncope two years after hysterectomy.A 61-year-old woman presented to the emergency department after experiencing palpitations, shortness of breath, and syncope while taking a shower. Her husband revived her with mouth-to-mouth resuscitation. She had had a similar episode three days earlier while making her bed and had lost consciousness for about 10 sec. She did not appear to have had a seizure. Five months earlier, while taking a walk, she had experienced dizziness, dyspnea, and chest pressure lasting about an hour. A workup at that time included cardiac catheterization, lung scanning, and esophagogastroduodenoscopy, but no abnormality was found. lower extremity edema was noted.- - - - - - - - - - ranking = 1keywords = consciousness (Clic here for more details about this article) |
2/84. back pain and collapse associated with receding subarachnoid blockade.PURPOSE: back pain and sudden loss of consciousness during recovery from spinal anesthesia are rare. Severe pain may raise fears of serious neurological damage and result in inappropriate management. Bladder distention may present in this way and clinicians should be alert to this possibility and communicate this to nursing staff. CLINICAL FEATURES: A lumbar spinal anesthetic was performed during a volunteer study, using 15 mg hyperbaric bupivacaine in a healthy 31 yr old man. During recovery, five hours later, as the block regressed to the L1-2 level, he complained of acute, severe back pain and briefly lost consciousness secondary to profound bradycardia. Bladder cathetherization yielded 900 mL urine with immediate and complete relief of symptoms. CONCLUSION: Severe pain secondary to bladder overdistention in the presence of neuroaxial blockade may be referred to the thoracolumbar area, mediated by intact sympathetic afferents. As the saccral parasympathetic supply remains paralyzed, there is no subjective sensation of bladder stretching. If untreated, bladder distention can lead to excessive supraspinal parasympathetic outflow resulting in vasovagal syncope.- - - - - - - - - - ranking = 2keywords = consciousness (Clic here for more details about this article) |
3/84. Autonomic dysfunction in end-stage liver disease manifested as defecation syncope: impact of orthotopic liver transplantation.patients with end-stage liver disease (ESLD) may be at increased risk for syncopal episodes based on their circulatory physiological state. Although a definitive cause for this is not known, several mechanisms have been proposed. In patients with ESLD, defecation syncope may result from a failure of short-term neurocirculatory adaptation to the valsalva maneuver in the face of a hyperdynamic circulatory state and a decreased effective intravascular volume. We describe 2 patients with ESLD who had repeated episodes of defecation syncope before orthotopic liver transplantation (OLT). The most effective treatment of these syncopal episodes appears to be fluid administration and the use of a pressor agent, such as dopamine, to help maintain both an effective heart rate and intravascular volume. Correction of this altered circulatory physiological state through OLT prevented further syncopal episodes in both patients. A search of the literature failed to show previous reports associating ESLD and defecation syncope. Possible mechanisms favoring this association are reviewed.- - - - - - - - - - ranking = 0.00084592232842287keywords = state (Clic here for more details about this article) |
4/84. Case report of an aviator with a single episode of altered consciousness due to hymenoptera hypersensitivity.This case is presented to: a) emphasize the importance of a careful history, including interviewing witnesses and considering a complete differential diagnosis when evaluating aviators with a history of an episode of altered consciousness; and b) demonstrate an appropriate use of literature review, subspecialty consultations, and U.S. air Force Aeromedical Guidelines to arrive at an aeromedical disposition for an unusual case. A military aviator experienced an episode of syncope/near syncope, initially felt to be caused by a primary seizure or an arrhythmia. Subsequent thorough evaluation included careful history taking, extensive interviewing of witnesses, subspecialty consultations, review of appropriate literature and deliberation by a board of experienced military aeromedical physicians. Cardiac and neurologic diagnoses were considered but careful history and witness interviews revealed that the aviator had sustained an insect sting just minutes before the episode. Evaluation by allergy specialists, including skin testing, identified him as being hypersensitive to hymenoptera stings. A diagnosis of hypersensitivity reaction to a hymenoptera sting was determined to be the cause of the altered consciousness episode. review of the literature revealed that immunotherapy for hymenoptera sensitivity reduces the risk of future anaphylaxis to only 1-2% after maintenance dose is achieved. Consideration of the risk of future events and the success of rush immunotherapy resulted in a recommendation for a waiver to return the aviator to unrestricted flying duties. The importance of diligent history taking must never be forgotten. In this aviator it led to the correct diagnosis and definitive therapy. In addition, appropriate consideration of the literature and knowledge of outcome rates allowed a return to unrestricted flying for this aviator. If the original diagnosis of seizure or arrhythmia had been accepted, this aviator would have been disqualified without waiver and a valuable flying asset would have been lost.- - - - - - - - - - ranking = 6keywords = consciousness (Clic here for more details about this article) |
5/84. syncope caused by nonsteroidal anti-inflammatory drugs and angiotensin-converting enzyme inhibitors.A 85-year-old woman with diabetes mellitus and prior myocardial infarction was transferred to the emergency room with loss of consciousness due to marked bradycardia caused by hyperkalemia. The T wave during right ventricular pacing was tall and tent-shaped while the concentration of serum potassium was high, and its amplitude during pacing was decreased after correction of the serum potassium level. Simultaneously with the correction, normal sinus rhythm was restored. The cause of hyperkalemia was considered to be several doses of loxoprofen, a nonsteroidal anti-inflammatory drug (NSAID), prescribed for her lumbago by an orthopedic specialist, in addition to the long-term intake of imidapril, an angiotensin-converting enzyme inhibitor (ACEI), prescribed for her hypertension by a cardiologist. This case warns physicians that the combination of NSAID and ACEI can produce serious side effects in aged patients who frequently suffer from hypertension, diabetes mellitus, ischemic heart disease, and degenerative joint disease.- - - - - - - - - - ranking = 1keywords = consciousness (Clic here for more details about this article) |
6/84. orthostatic intolerance and tachycardia associated with norepinephrine-transporter deficiency.BACKGROUND: orthostatic intolerance is a syndrome characterized by lightheadedness, fatigue, altered mentation, and syncope and associated with postural tachycardia and plasma norepinephrine concentrations that are disproportionately high in relation to sympathetic outflow. We tested the hypothesis that impaired functioning of the norepinephrine transporter contributes to the pathophysiologic mechanism of orthostatic intolerance. methods: In a patient with orthostatic intolerance and her relatives, we measured postural blood pressure, heart rate, plasma catecholamines, and systemic norepinephrine spillover and clearance, and we sequenced the norepinephrine-transporter gene and evaluated its function. RESULTS: The patient had a high mean plasma norepinephrine concentration while standing, as compared with the mean ( /-SD) concentration in normal subjects (923 vs. 439 /-129 pg per milliliter [5.46 vs. 2.59 /-0.76 nmol per liter]), reduced systemic norepinephrine clearance (1.56 vs. 2.42 /-0.71 liters per minute), impairment in the increase in the plasma norepinephrine concentration after the administration of tyramine (12 vs. 56 /-63 pg per milliliter [0.07 vs. 0.33 /-0.37 pmol per liter]), and a disproportionate increase in the concentration of plasma norepinephrine relative to that of dihydroxyphenylglycol. Analysis of the norepinephrine-transporter gene revealed that the proband was heterozygous for a mutation in exon 9 (encoding a change from guanine to cytosine at position 237) that resulted in more than a 98 percent loss of function as compared with that of the wild-type gene. Impairment of synaptic norepinephrine clearance may result in a syndrome characterized by excessive sympathetic activation in response to physiologic stimuli. The mutant allele in the proband's family segregated with the postural heart rate and abnormal plasma catecholamine homeostasis. CONCLUSIONS: Genetic or acquired deficits in norepinephrine inactivation may underlie hyperadrenergic states that lead to orthostatic intolerance.- - - - - - - - - - ranking = 0.00028197410947429keywords = state (Clic here for more details about this article) |
7/84. Autonomic seizures versus syncope in 18q- deletion syndrome: a case report.PURPOSE: The 18q- deletion syndrome (18qDS) is frequently associated with cardiac anomalies. patients with this syndrome may also have epilepsy, which presents certain diagnostic difficulties. This case report aims to illustrate these diagnostic problems, document the usefulness of heart rate-based seizure detection algorithms in this setting, and define the epilepsy syndrome associated with 18qDS. methods: Closed-circuit video electroencephalogram (EEG) monitoring using a heart rate-based seizure detection software was used to identify the event in question and to establish the diagnosis of epilepsy. Chromosomal analysis and magnetic resonance imaging (MRI) were used to further define the epilepsy syndrome. RESULTS: We report on a patient with an atrial septal defect, enlargement of the right heart, and incomplete right bundle branch block, who developed episodes of tachycardia, loss of consciousness, and pallor, for which he was amnesic. Chromosomal analysis demonstrated karyotype 46,XY,del(18)(q21.3). ish del(18)(wcp18 ,D18Z1 ) with a loss of the gene for myelin basic protein. MRI revealed multifocal dysmyelination. Video-EEG monitoring using an electrocardiogram (ECG)-triggered seizure detection software proved to be indispensable in detecting an autonomic seizure and establishing the correct diagnosis; the procedure also allowed for the definition of the epilepsy syndrome. The patient was treated with carbamazepine and remained seizure-free. CONCLUSIONS: Video-EEG monitoring using a heart rate-based seizure detection software can be helpful in diagnostically differentiating autonomic seizures from syncope. Dysmyelination due to loss of the myelin basic protein gene on 18q and cortical dysgenesis may be of pathogenic relevance.- - - - - - - - - - ranking = 1keywords = consciousness (Clic here for more details about this article) |
8/84. Recurrent seizure diagnosed by the insertable loop recorder.INTRODUCTION: The Insertable Loop Recorder (ILR) has emerged as an important new tool in the diagnostic armamentarium for patients with syncope. methods AND RESULTS: A case report illustrates how the ILR unexpectedly led to the diagnosis of seizure as the explanation for a man's recurrent, but infrequent episodes of sudden loss of consciousness. CONCLUSIONS: This case raises the possibility that the development of implantable recording devices which monitor physiologic parameters other than cardiac rhythm (eg. brain, nerve or muscle activity) may provide the long-term monitoring capability needed to improve the diagnostic yield for conditions, such as seizures, which occur infrequently.- - - - - - - - - - ranking = 1keywords = consciousness (Clic here for more details about this article) |
9/84. exercise induced hypoglycaemic hyperinsulinism.BACKGROUND: hyperinsulinism in childhood is often caused by genetic defects involving the regulation of insulin secretion leading to recurrent episodes of hypoglycaemia. We report two patients with exercise induced hypoglycaemia. methods: Standardised short exercise tests with frequent blood glucose and plasma insulin measurements were performed in the patients and young healthy controls. RESULTS: Short term exercise resulted in insulin induced hypoglycaemia 15 to 50 minutes after the end of exercise. A massive burst of insulin secretion was observed within a few minutes of the start of exercise in both patients. By contrast glucose and insulin concentrations remained unchanged in healthy controls. CONCLUSIONS: Hyperinsulinaemic hypoglycaemia after moderate physical exercise represents a rarely described phenotype of hyperinsulinism with an as yet unknown defect in the regulation of insulin secretion. It should be suspected in individuals with recurrent exercise related syncope or disturbance of consciousness.- - - - - - - - - - ranking = 1keywords = consciousness (Clic here for more details about this article) |
10/84. Valsalva-induced syncope during apnea diving.A young man had two dangerous episodes of transient loss of consciousness during apnea diving in a swimming pool. Medical and neurologic examination results were normal. Standard autonomic test results (including heart rate variability, baroreflex sensitivity, tilt-table test, and Valsalva ratio) were unremarkable, with the exception of an increased blood pressure decrease during early phase II of the valsalva maneuver. syncope with arrhythmic myoclonic jerks could be evoked by a strong straining maneuver. Simultaneous physiologic recordings showed extreme blood pressure and cerebral blood flow velocity decreases and electroencephalographic slowing during syncope. The electrocardiogram showed a continuous sinus rhythm with a progressive tachycardia. The authors' findings were not compatible with baroreflex failure or vasovagal mechanisms (Bezold-Jarisch reflex activation) as the underlying causes. The authors concluded that mechanical factors (strong reduction of blood reflux to the heart) in combination with a reduced threshold of the brain for developing ischemia-related arrhythmic myoclonic jerks were responsible for Valsalva-induced syncope in the patient.- - - - - - - - - - ranking = 1keywords = consciousness (Clic here for more details about this article) |
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