Spontaneous Intracranial Hypotension Without CSF Leakage—Concept of a Pathological Cranial to Spinal Fluid Shift

Objective: Spontaneous intracranial hypotension (SIH) is typically caused by CSF leakage from a spinal dural tear, a meningeal diverticulum, or a CSF venous fistula. However, some patients present with classic orthostatic symptoms and typical intracranial imaging findings without evidence of CSF leakage despite repeated diagnostic work-up. This article aims to elaborate a hypothesis that would explain a pathologically increased orthostatic shift of CSF from the cranial to the spinal compartment in the absence of a CSF leak.Medical Hypothesis: The symptoms of SIH are caused by a decrease in intracranial CSF volume, intracranial hypotension, and downward displacement of intracranial structures. A combination of pathologically increased spinal compliance, decreased intracranial CSF volume, low CSF outflow resistance, and decreased venous pressure might result in a pathological orthostatic cranial-to-spinal CSF shift. Thus, in rare cases, intracranial hypotension may occur in the absence of CSF leakage from the dural sac.Conclusion: We propose a pathophysiological concept for the subgroup of SIH patients with typical cranial imaging findings and no evidence of CSF leakage. In these patients, reducing the compliance or the volume of the spinal compartment seems to be the appropriate therapeutic strategy.

Abstract 49: Supine Versus Seated Positions On The Detection Of Orthostatic Hypotension And Its Association With Fall Risk And Orthostatic Symptoms

Background: Hypertension trials that monitor orthostatic hypotension (OH) compare standing to seated blood pressure (BP) rather than supine BP. We determined the impact of a supine vs seated position on OH prevalence and its relationship with fall risk and orthostatic symptoms. Methods: The Study to Understand Fall Reduction and Vitamin D in You (STURDY) was a randomized trial testing the effects of vitamin D3 dose on falls in adults age ≥70 years at higher risk of falls. OH was determined at baseline, 3, 12, and 24 months with each of 2 protocols: (1) seated to standing and (2) supine to standing. OH was defined as a drop in systolic or diastolic BP of at least 20 or 10 mm Hg. Participants were asked about orthostatic symptoms in the past month. Falls were ascertained via daily fall calendar, ad hoc reporting, and scheduled interviews. Results: Among 522 participants with 953 OH assessments (mean age 76 ± 5 years, 42% women, 18% Black), mean baseline BP was 129 ± 18/68 ± 11 mm Hg. Mean BP increased 3.4/2.6 mm Hg after sitting, but decreased -3.7/-0.7 mm Hg after being supine. OH was detected in 2.2% of seated vs 14.8% of supine assessments. Supine OH better predicted falls (HR 1.60; 95% CI: 0.98, 2.61; P =0.06) than seated OH (HR 0.70; 95% CI: 0.30, 1.60; P =0.39), although both were non-significant ( Figure ). While seated OH was not associated with orthostatic symptoms, supine OH was associated with a greater risk of fainting, blacking out, seeing spots, room spinning, and headache in the prior month ( P -values of 0.048 to 0.002). Conclusions: Supine OH was more prevalent and appeared to better predict falls and orthostatic symptoms than seated OH. These findings support a supine protocol for OH in clinical practice.

Abstract P204: Sinusoidal Galvanic Stimulation Improves Orthostatic Symptoms In Patients With Postural Tachycardia.

Postural Tachycardia Syndrome (POTS) is characterized by frequent orthostatic symptoms and excessive heart rate increase (>= 30 bpm) on standing in the absence of orthostatic hypotension for more than 6 months. We and others have described a vestibulo-sympathetic reflex that can be engaged by galvanic vestibular stimulation to modulate sympathetic activity (Biaggioni et al., 2000; Kaufmann et al., 2002; Monahan & Ray, 2002; Ray & Carter, 2003, Bent, Macefield et al. 2006). We hypothesize that habituation to sinusoidal galvanic vestibular stimulation will improve orthostatic tolerance. We studied 6 patients with POTS (30.5+/6.0 years, BMI 22.8+/-2.9 kg/m 2 ) in two sessions using sinusoidal galvanic vestibular stimulation (sGVS 0.025 Hz, 2mA) or sham (0.01 mA). Stimulation was applied near mastoid process for 30 min in semi-recumbent position before orthostatic challenge. Patient were upright for a maximum of 15 minutes after each stimulation. Orthostatic change in Vanderbilt Orthostatic Symptom Score (dVOSS), orthostatic heart rate increase (dHR) and blood pressure response were recorded. Non-parametric Wilcoxon test for paired measures with significance level p<0.05 was used. sGVS stimulation reduced overall orthostatic symptom score (dVOSS sham: 32.5+/-9.3 bpm vs dVOSS sGVS: 10.5+/-5.5, p=0.03) and tended to reduce orthostatic HR increase (dHR sham: 65.83+/-11.5 vs dHR sGVS: 46.5+/-10.7 bpm, p=0.06). Blood pressure and tilt time did not change. This pilot study suggests that habituation to sinusoidal vestibular could be used to improve orthostatic symptoms and orthostatic tolerance.

Abstract P128: Direct Observed Therapy In Suspected Resistant Hypertension Is Safe

Introduction: Direct observed therapy (DOT) has emerged as a method for assessment of adherence, particularly in patients with apparent treatment-resistant hypertension (ATRH), in clinical care as well as research. We have previously demonstrated that direct observed therapy resulted in controlled hypertension in 30% of patients with ATRH. In this study we report on the safety of DOT in terms of change in blood pressure (BP) and hypotensive symptoms. Methods: Patients with ATRH were enrolled in a prospective study of DOT, which was followed by ambulatory blood pressure monitoring on the same day and at one month. DOT was performed by administering all prescribed BP lowering drugs, supervised by a nurse in an outpatient clinic setting. BP and vitals were measured at baseline and every 30 minutes until BP plateau based on two consecutive BP readings. All BP measurements during DOT were performed using an automated oscillometric BP device. In this study, we report the change in BP during DOT, with incidence of orthostatic symptoms, and decrease in systolic BP > 20 mm Hg as outcomes of interest. Results: 50 patients underwent DOT, 32 men, mean age 62 years on median 4 BP lowering drugs (range 3 to 7). The mean baseline BP was 146/77 mm Hg , and the lowest BP during DOT was 129/68 mm Hg. The median decrease in systolic BP was 14 mm Hg (range 0 to 60) and diastolic BP was 8 mm Hg (range 0 to 37). 5 patients (10%) developed orthostatic symptoms during DOT, none of which required any interventions, and resolved with continued observation. A decrease of > 20 mm Hg in systolic BP was seen in 19 patients (38%), and a systolic BP of < 110 mm Hg was seen in only 6 patients (12%). Conclusions: DOT caused decrease in BP by >20 mmHg in about 40% of patients. While these large acute decreases in BP were largely asymptomatic, close observation of BP is required until peak BP lowering effect wanes. As decrease in BP is driven by the degree of non-adherence and number of prescribed BP lowering drugs, our safety record has limitation dictated by the number of subjects enrolled, and relatively small number of patients with more than 5 BP lowering drugs.

From Normal Cognition to Cognitive Impairment and Dementia: Impact of Orthostatic Hypotension

The role of orthostatic hypotension (OH) in the continuum of cognitive aging remains to be clarified. We sought to investigate the associations of OH with dementia, cognitive impairment, no dementia (CIND), and CIND progression to dementia in older adults while considering orthostatic symptoms. This population-based cohort study included 2532 baseline (2001–2004) dementia-free participants (age ≥60 years; 62.6% women) in the SNAC-K (Swedish National Study on Aging and Care in Kungsholmen) who were regularly examined over 12 years. We further divided the participants into a baseline CIND-free cohort and a CIND cohort. OH was defined as a decrease by ≥20/10 mm Hg in systolic/diastolic blood pressure upon standing and further divided into asymptomatic and symptomatic OH. Dementia was diagnosed following the international criteria. CIND was defined as scoring ≥1.5 SDs below age group-specific means in ≥1 cognitive domain. Data were analyzed with flexible parametric survival models, controlling for confounding factors. Of the 2532 participants, 615 were defined with OH at baseline, and 322 were diagnosed with dementia during the entire follow-up period. OH was associated with an adjusted hazard ratio of 1.40 for dementia (95% CI, 1.10–1.76), 1.15 (0.94–1.40) for CIND, and 1.54 (1.05–2.25) for CIND progression to dementia. The associations of dementia and CIND progression to dementia with asymptomatic OH were similar to overall OH, whereas symptomatic OH was only associated with CIND progression to dementia. Our study suggests that OH, even asymptomatic OH, is associated with increased risk of dementia and accelerated progression from CIND to dementia in older adults.

Abstract P125: The Effects Of Vitamin D Supplementation On Orthostatic Hypotension: Results From STURDY

Background: In some trials, vitamin D supplementation is associated with a lower risk of falls. Observational evidence has implicated orthostatic hypotension (OH) as a potential mechanism for this association. Objective: To determine if higher doses of vitamin D supplementation reduce the risk of OH. Methods: The Study to Understand Fall Reduction and Vitamin D in You (STURDY) was a double-blind, randomized, response-adaptive trial that tested the effects of 4 doses of vitamin D3 (200, 1000, 2000, and 4000 IU/day) on fall risk in adults age 70 years and older with low serum vitamin D levels (10-29 ng/ml). OH was determined at baseline, 3, 12, and 24 months by taking the difference between seated and standing blood pressure. OH was defined as a drop in systolic or diastolic blood pressure of at least 20 or 10 mmHg, respectively, after 1 minute of standing. Participants were also asked about symptoms related to OH during the OH assessment and in the past month. Odds ratios were determined using generalized estimating equations to account for repeat measurements. Results: Among 387 participants with 924 OH assessments, mean age was 77 ± 5 years, 42% were women, and 17% black. Mean baseline systolic/diastolic blood pressure was 129 ± 19/67 ± 11 mm Hg; 2.3% had OH. Compared to 200 IU/day, 1000, 2000, and 4000 IU/day did not lower risk of OH during the trial ( Table ). Furthermore, vitamin D dose was not associated with orthostatic symptoms as participants stood up or after standing. In a subset with more detailed symptom assessments, there was no association between vitamin D dose and orthostatic symptoms or functional limitations in the preceding 30 days. Conclusions: Daily, higher dose vitamin D supplementation was not associated with OH or its symptoms. These findings do not support vitamin D as an intervention to prevent OH.

Too much of a good thing: a case report of traumatic drop attacks and syncope due to orthostatic hypertension

Background Orthostatic hypertension (OHT) is the clinical opposite to orthostatic hypotension and is an under-recognized and poorly understood clinical phenomenon. Patients may experience disabling symptoms such as dizziness, chest pain, and shortness of breath. In addition, OHT is associated with important clinical outcomes such as silent cerebral infarcts and cognitive decline. Case summary We present the case of a 67-year-old female who experienced frequent drop attacks with and without transient loss of consciousness causing various injuries. A range of standard diagnostic procedures did not yield an explanation for her symptoms but head-up tilt (HUT) testing showed OHT and induced most of her symptoms. Upon initiation of doxazosin, an alpha-blocking drug, she was free of symptoms and blood pressure response was normal on the repeat HUT test. Discussion To our knowledge, this is the first report of syncope due to OHT. Orthostatic hypertension is a heterogeneous condition and may occur in young, otherwise healthy individuals but also in older patients with cardiovascular comorbidities. It is thought that symptoms occur because of excessive venous pooling (causing a drop in cardiac output) or adrenergic hypersensitivity (resulting in cerebral vasoconstriction or acute rise in cardiac afterload). Since our patient had a marked response to an alpha-blocking agent, we think baroreflex hypersensitivity is the most likely cause of her complaints. Though syncope is probably rare, OHT should be regarded as a possible explanation of orthostatic symptoms.

Orthostatic hypotension. Part 2: diagnosis and treatment

Since orthostatic hypotension is largely asymptomatic, performing an orthostatic challenge is considered as the main mean to diagnose it. One should try to define the causes of orthostatic hypotension in every single case as treating illness that lead to orthostatic hypotension will improve patient’s health outcomes. The main target for therapy should be improving patient’s functional status, reducing orthostatic symptoms as well as risk for falls and syncopes, but not maintaining arterial blood pressure within certain limits. The higher the doctors’ awareness of the methods used to diagnose the orthostatic hypotension, the better patient’s quality of life will be. The first part of the systematic review was published in the Innovative Medicine of Kuban, nr. 4, 2018.

Nutcracker syndrome mimicking new daily persistent headache: A case report

Introduction Compression of the duodenum and left renal vein between the aorta and superior mesenteric artery usually leads to symptoms of proximal bowel obstruction or hematuria and, more rarely, nonspecific mild headaches. Case A young woman presented with new daily persistent headache refractory to numerous pharmacological treatments, onabotulinumtoxinA, nerve blocks, and occipital nerve stimulation. Following several years of daily severe headache, worsening abdominal pain and intolerance for food intake led to the discovery of aortomesenteric compression. Surgical treatment gave prompt improvement in gastric symptoms but also essentially resolved the headache. Conclusion This is the first description of new daily persistent headache in association with aortomesenteric compression as well as marked improvement of headache following aortomesenteric decompression. In patients with new daily persistent headache and orthostatic symptoms one may consider a differential diagnosis of Nutcracker syndrome, especially in patients with comorbid hypermobility syndromes, hematuria or gastric symptoms.