Search

Falx interhemispheric subdural hematoma (FISH) is a rare subtype of subdural hematoma that occurs between the cerebral hemispheres along with falx cerebri. It represents less than 0.5% of all subdural hematomas and is frequently misdiagnosed due to its rarity and nonspecific clinical presentation. We present a case of 59-year-old female with a history of urticaria and hypertension who developed FISH following minor head trauma. The patient experienced presyncope, nausea, dizziness, and headache. A non-contrast computed tomography (CT) scan of the head revealed FISH, and the patient was managed conservatively without surgical intervention. This case report highlights the importance of considering FISH in the differential diagnosis of patients presenting with headache, dizziness, and presyncope, particularly in the setting of minor head trauma. We discuss the potential relationship between FISH, urticaria, and hypertension, as well as the possible causes of presyncope in this case, including orthostatic hypotension probably due to vagal nerve stimulation. Indeed, further studies are needed to explore these associations and to better understand the underlying mechanisms.

目的 分析血管迷走性晕厥患者的临床特点，探讨其晕厥前是否有晕厥先兆的影响因素。 方法 回顾性纳入2017年1月—2022年6月首都医科大学附属北京天坛医院诊治的血管迷走性晕厥患者为研究对象。采集其一般资料、直立倾斜试验结果及血流动力学指标，采用多因素logistic回归分析探讨患者发生晕厥先兆的影响因素。 结果 研究共纳入血管迷走性晕厥患者1211例。根据其发生晕厥前是否有先兆症状进行分组，其中无先兆组582例（48.06%），有先兆组629例（51.94%）。有先兆组患者的年龄（t=6.006，P

Copyright of Chinese Journal of Stroke is the property of Chinese Journal of Stroke Editorial Office and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: Syncope is a temporary loss of consciousness with a loss of postural tone. Medicinal treatment of reflex syncope has shown to have no significant effect in reducing the recurrence of syncope. A 36-month follow-up of our pilot cohort showed that non-pharmacological treatments alone were effective in reducing relapse rates. The purpose of this study is to investigate long-term results and 8-year follow-up of previous patients. Methods: The current study is a continuation of a prospective pilot cohort which was done between August 2013 and 2014 in two academic hospitals in Isfahan (Dr. Chamran heart center and Imam Hossein children hospitals). This current study examines the 8-year follow-up results of children with reflex syncope who were treated with non-pharmacological treatments alone or with drugs. Therefore, the patients who participated in the pilot study were enrolled (30 patients in the pharmacologic group and 40 patients non-pharmacological group). Finally, on 26 patients in the pharmacologic group and 31 patients in the non-pharmacological group (after applying the exclusion criteria), the incidence of syncope and pre-syncope attacks was compared between these two groups of patients using the Chi-square test. Results: Our study showed that within 5 years after the last follow-up, the incidence of syncope and pre-syncope in patients with a history of vasovagal syncope who did not continue the diet or tilt exercises was different between the two groups of patients (without medication and drug recipient) was not significantly different, even the incidence of presyncope increased significantly again in both groups. The incidence of syncope in the period of 5 years after the last follow-up from the previous study was slightly increased in the group of patients without medication compared to the previous periods, but in the group of patients receiving medication, this incidence decreased slightly. Conclusion: In order to prevent recurrence, the use of non-pharmacological methods is effective, but for the stability of this recovery, follow-up and continuation of these methods is necessary.

Objective: This study aimed to analyse whether referral for specialist balance testing influences diagnosis and management of patients with dizziness. Method: This was a retrospective study examining patients referred for vestibular function testing between 1 January 2018 and 30 June 2018. Results: A total of 101 patients were referred, with 69 patients (68.3 per cent) receiving a preliminary 'pre-vestibular function testing balance diagnosis', which included benign paroxysmal positional vertigo (32.7 per cent), Ménière's disease (13.8 per cent) and migraine (14.9 per cent). Following vestibular function testing, revised diagnoses were achieved for 54 patients (53.5 per cent), including benign paroxysmal positional vertigo (14.9 per cent), Ménière's disease (3.0 per cent) and migraine (10.9 per cent). Pre-vestibular function testing balance diagnoses were confirmed for 32.4 per cent of patients. If no pre-vestibular function testing suspected diagnosis was provided, vestibular function testing was significantly more likely to be inconclusive. Following vestibular function testing, 38.6 per cent were discharged, 21.7 per cent were referred to another specialty and treatment was commenced for 17.8 per cent of patients. Conclusion: Referral for vestibular function testing has a role when attempting to answer a clear clinical question. Diagnosing the underlying aetiology of complex imbalance is challenging, but diagnosis can be assisted by judicious use of vestibular function testing. [ABSTRACT FROM AUTHOR]

The emergency physician should diagnose and treat the critical illnesses that cause syncope/presyncope in patients presenting to the emergency department (ED). Whole-body ultrasonography can detect the critical etiology of syncope with high diagnostic sensitivity. We aimed to reveal whether whole-body ultrasonography for syncope (WHOBUS-Syncope) protocol recognizes high-risk syncope patients and the effect of WHOBUS-Syncope protocol on the management of patients. This is a prospective, cross-sectional study. Patients over the age of 18 years who presented to the ED with syncope or near syncope were included consecutively. Carotid, lung, cardiac, collapsibility of inferior vena cava, abdominal and compression ultrasonography of the lower extremity veins was performed among the WHOBUS-Syncope protocol. Frequency of abnormal sonographic findings associated with syncope/presyncope and requirement of critical intervention for abnormal sonographic findings were assessed. 152 patients were included in the study. The median age of the patients was 61.5 years (IQR: 41–71.8) and 52.6% were female. The most common (64.3%) abnormal sonographic finding was >50% collapse of vena cava inferior during inspiration. In addition, abnormal sonographic findings thought to cause syncope/presyncope were detected in 35.5% of the patients. Bolus fluid resuscitation were given in in 62 patients (40.8%) with increased inferior vena cava collapse. Critical interventions other than fluid resuscitation were performed for abnormal sonographic findings in 35 (23%) of the patients. Advanced age, increased heart rate and the presence of high-risk criteria in the 'European Society of Cardiology Guidelines for Syncope' were independent risk factors for detection of abnormal ultrasonographic findings related to syncope/presyncope. WHOBUS-Syncope protocol can be included in emergency practice as part of the standard evaluation in patients with syncope or presyncope presenting to the ED. • Ultrasonography protocols are not routinely used to identify high-risk syncope patients. • WHOBUS syncope protocol has been used successfully in the diagnostic evaluation of syncope and near syncope patients. • Many patients received critical treatments or interventions due to abnormal findings detected in the WHOBUS syncope protocol. • WHOBUS syncope protocol can be integrated into standard evaluation in syncope patients. [ABSTRACT FROM AUTHOR]

Background: Syncope is a temporary loss of consciousness with a loss of postural tone. Medicinal treatment of reflex syncope has shown to have no significant effect in reducing the recurrence of syncope. A 36-month follow-up of our pilot cohort showed that non-pharmacological treatments alone were effective in reducing relapse rates. The purpose of this study is to investigate long-term results and 8-year follow-up of previous patients. Methods: The current study is a continuation of a prospective pilot cohort which was done between August 2013 and 2014 in two academic hospitals in Isfahan (Dr. Chamran heart center and Imam Hossein children hospitals). This current study examines the 8-year follow-up results of children with reflex syncope who were treated with non-pharmacological treatments alone or with drugs. Therefore, the patients who participated in the pilot study were enrolled (30 patients in the pharmacologic group and 40 patients non-pharmacological group). Finally, on 26 patients in the pharmacologic group and 31 patients in the non-pharmacological group (after applying the exclusion criteria), the incidence of syncope and pre-syncope attacks was compared between these two groups of patients using the Chi-square test. Results: Our study showed that within 5 years after the last follow-up, the incidence of syncope and pre-syncope in patients with a history of vasovagal syncope who did not continue the diet or tilt exercises was different between the two groups of patients (without medication and drug recipient) was not significantly different, even the incidence of presyncope increased significantly again in both groups. The incidence of syncope in the period of 5 years after the last follow-up from the previous study was slightly increased in the group of patients without medication compared to the previous periods, but in the group of patients receiving medication, this incidence decreased slightly. Conclusion: In order to prevent recurrence, the use of non-pharmacological methods is effective, but for the stability of this recovery, follow-up and continuation of these methods is necessary. [ABSTRACT FROM AUTHOR]

Vasovagal presyncope and syncope while attending operating theatres have been reported among medical trainees. However, no such studies are available in relation to dental trainees. The aim of this study was to investigate the prevalence, preventative measures and attitudes towards these events among dental trainees. An anonymised online questionnaire was sent to all dental core trainees in the Thames Valley and Wessex regions (n = 34). Nineteen of these participated (56% response rate). Ten (53%) had experienced a presyncopal or syncopal episode. The majority had experienced an episode during a major operation. High operating room temperatures and needing to stand for a long time were reported as the most common predisposing factors (60%). Several different actions were taken to prevent further episodes, with 90% of respondents reporting that these helped. Seven trainees expressed their desire to pursue a surgical career; five of these had experienced a vasovagal event. Most (78%) felt that this would not discourage them from following a career in surgery. Seven respondents felt that there was a perceived stigma about trainees who experienced such an episode. This study revealed that operating theatre related syncope is common among dental trainees. We highlight the importance of educating trainees on preventative strategies. [ABSTRACT FROM AUTHOR]

Objective: Syncope, whose cause is unknown after an initial assessment, has an uncertain prognosis. It is critical to identify patients at the highest risk who may require a pacemaker and to identify the cause of recurrent syncope to prescribe proper therapy. The aim of this study was to evaluate the effect of permanent pacing on the incidence of syncope in patients with unexplained syncope and electrophysiology study (EPS)-proven atrioventricular (AV) node disease. Methods: This was an observational study based on a prospective registry of 236 consecutive patients (60.20 ± 18.66 years, 63.1% male, 60.04 ± 9.50 bpm) presenting with recurrent unexplained syncope attacks admitted to our hospital for invasive EPS. The decision to implant a permanent pacemaker was made in all cases by the attending physicians according to the results of the EPS. A total of 135 patients received the antibradycardia pacemaker (ABP), while 101 patients were declined. Results: The mean of reported syncope episodes was 1.97 ± 1.10 (or presyncope 2.17 ± 1.50) before they were referred for a combined EP-guided diagnostic and therapeutic approach. Over a mean follow-up of approximately 4 years (49.19 ± 29.58 months), the primary outcome event (syncope) occurred in 31 of 236 patients (13.1%), and 6 of 135 (4.4%) patients in the ABP group as compared to 25 of 101 (24.8%) in the no pacemaker group (p

The relationship between SARS-CoV-2 infection and dizziness is still unclear. The aim of this study is to assess the prevalence and characteristics of dizziness and vertigo among patients with mild-to-moderate COVID-19. Patients discharged from the emergency rooms with a confirmed SARS-CoV-2 diagnosis were assisted by daily telephone calls until nasopharyngeal swab negativization, and specific symptoms concerning balance disorders were investigated through targeted questions posed by experienced physicians. The study included 1512 subjects (765 females, 747 males), with a median age of 51 ± 18.4 years. New-onset dizziness was reported by 251 (16.6%) patients, among whom 110 (43.8%) complained of lightheadedness, 70 (27.9%) of disequilibrium, 41 (16.3%) of presyncope, and 30 (12%) of vertigo. This study analyzed in detail the prevalence and pathophysiological mechanisms of the different types of balance disorders in a large sample, and the results suggest that dizziness should be included among the main symptoms of COVID-19 because one-sixth of patients reported this symptom, with females being significantly more affected than males (20.3 vs 12.9%, P < 0.001). Most cases of dizziness were attributable to lightheadedness, which was probably exacerbated by psychophysical stress following acute infection and mandatory quarantine. Vertigo should not be underestimated because it might underlie serious vestibular disorders, and disequilibrium in elderly individuals should be monitored due to the possible risk of falls. [ABSTRACT FROM AUTHOR]

Syncope of cardiac origin may be associated with an increased risk of sudden cardiac death if not treated in a timely and appropriate manner. The diagnostic approach of syncope imposes a significant economic burden on society. The investigation and elucidation of the pathogenetic mechanism of syncope are of great clinical importance, as both prognosis and appropriate therapeutic approaches depend on these factors. The responsible mechanism of presyncope or syncope can only be revealed through the patient history, baseline clinical examination and electrocardiogram. The percentage of patients who are diagnosed with these tests alone exceeds 50%. In patients with a history of organic or acquired heart disease or/and the presence of abnormal findings on the electrocardiogram, a further diagnostic electrophysiology inclusive approach should be followed to exclude life threatening arrhythmiological mechanism. However, if the patient does not suffer from underlying heart disease and does not show abnormal electrocardiographic findings in the electrocardiogram, then the probability in the electrophysiology study to find a responsible cause is small but not absent. The role of a two-step electrophysiology study inclusive risk stratification approach for the effective management of the former is thoroughly discussed in this review.

Several portable devices for ECG acquisition are already available in the market and have provided valuable information regarding various cardiac arrhythmias, most commonly atrial fibrillation (AF). Such gadgets are easy to use and can impact health care for both diagnosis and management in a variety of clinical settings, such as in patients complaining of palpitations, patients presenting with unexplained presyncope or syncope, patients with heart failure and suspected tachycardiomyopathy, those afflicted by cryptogenic stroke, and/or patient groups who are at high arrhythmic risk (e.g., older persons, individuals with obesity, sleep apnea, hypertension, diabetes or structural heart disease). [ABSTRACT FROM AUTHOR]

Cytotoxic lesion of the corpus callosum (CLOCC) stems from a variety of causes such as malignancies, drug treatments, metabolic disorders, subarachnoid hemorrhage, and infections, and often presents as encephalitis or encephalopathy. During this pandemic, we saw 2 cases with this lesion; the first one was a 42-year-old male who presented to the emergency department with complaints of headache, fever, and cough. There was a ground-glass opacity in the thorax computed tomography, and diffusion restriction was found in the corpus callosum splenium in the cranial magnetic resonance imaging (MRI) performed for headache that did not resolve with analgesic treatment during hospitalization due to the preliminary diagnosis of Coronavirus diseases-2019 (COVID-19) pneumonia. In the second case, Severe Acute Respiratory syndrome Coronavirus-2 polymerase chain reaction was found to be positive in the examinations performed during his admission to the emergency service due to weakness and presyncope, and diffusion restriction was observed in the corpus callosum splenium like the first case in cranial imaging. The follow-up cranial MRI was normal in both cases, so they were diagnosed with CLOCC. We aimed to report the present cases with COVID-19 associated CLOCC since they presented only as a headache and a presyncope without any mental deterioration.

Background: Initial orthostatic hypotension (IOH) is a form of orthostatic intolerance defined by a transient decrease in blood pressure upon standing. Current clinical recommendations for managing IOH includes standing up slowly or lower body muscle tensing (TENSE) after standing. Considering that IOH is likely due to a large muscle activation response resulting in excessive vasodilation with a refractory period (<2 minutes), we hypothesized that preactivating lower body muscles (PREACT) before standing would reduce the drop in mean arterial pressure (MAP) upon standing and improve presyncope symptoms.Objective: The purpose of this study was to provide IOH patients with effective symptom management techniques.Methods: Study participants completed 3 sit-to-stand maneuvers, including a stand with no intervention (Control), PREACT, and TENSE. Continuous heart rate and beat-to-beat blood pressure were measured. Stroke volume and cardiac output were then estimated from these waveforms.Results: A total of 24 female IOH participants (mean ± SD: 32 ± 8 years) completed the study. The drops in MAP following PREACT (-21 ± 8 mm Hg; P <.001) and TENSE (-18 ± 10 mm Hg; P <.001) were significantly reduced compared to Control (-28 ± 10 mm Hg). The increase in cardiac output was significantly larger following PREACT (2.6 ± 1 L/min; P <.001) but not TENSE (1.9 ± 1 L/min; P = .2) compared to Control (1.4 ± 1 L/min). The Vanderbilt Orthostatic Symptom Score following PREACT (9 ± 8 au; P = .033) and TENSE (8 ± 8 au; P = .046) both were significantly reduced compared to Control (14 ± 9 au).Conclusion: Both the drop in MAP and symptoms upon standing improved with either PREACT or TENSE. These maneuvers provide novel symptom management techniques for patients with IOH. [ABSTRACT FROM AUTHOR]

Postural orthostatic tachycardia syndrome is an underdiagnosed disorder of the autonomic nervous system. The median time to achieve correct diagnosis is 2 years and may take more than 10 years for some patients. Symptoms can be devastating to the daily life of patients and can result in long-term disability. Treatment availability is limited due to the need for further studies. [ABSTRACT FROM AUTHOR]

Background Presyncope and syncope are common presentations with a wide range of differential diagnoses; when it occurs primarily on exertion, a cardiovascular cause is more likely. Structural abnormalities and primary rhythm disturbances are the usual culprits in these patients. Case summary A 75-year-old gentleman presented with a history of progressive exertional presyncope. His investigations demonstrated normal cardiac structure, function, and rhythm. He underwent an exercise stress test, which demonstrated a significant reduction in peak blood pressure with equivocal electrocardiogram changes and absence of ischaemic symptoms. In view of his age and gender, a computerized tomography coronary angiogram (CTCA) was organized to exclude obstructive coronary artery disease (CAD). Intriguingly, the CTCA demonstrated a severe proximal left anterior descending (LAD) artery stenosis. This stenosis was confirmed to be functionally significant using invasive coronary physiology and was treated with percutaneous coronary intervention. At follow-up, there was no recurrence of exertional presyncope and the patient was continuing to return to his baseline function. Conclusion Presyncope and/or syncope as the sole manifestation of obstructive CAD, in the presence of normal ventricular function and valves, has rarely been reported. Myocardial ischaemia-mediated presyncope and/or syncope may be secondary to numerous mechanisms, which are described in this case report. Revascularization of the functionally significant proximal LAD stenosis resulted in cessation of exertional presyncope in our patient. The long-term outcome of revascularization in patients with presyncope and syncope needs to be further investigated. [ABSTRACT FROM AUTHOR]

Competing Interests: Disclosures The authors have no conflicts of interest to disclose.

Background: Syncope is transient loss of consciousness, and in presyncope, patients experience same prodromal symptoms without losing consciousness. While studies have extensively reported the risk of serious outcome among emergency department (ED) syncope, the outcome for patients with presyncope and their management are not well studied. We undertook a systematic review to assess the occurrence/identification of short-term (30-day) serious outcomes among ED patients with presyncope., Methods: ED studies that enrolled patients with presyncope and reported any short-term serious outcome were included. Studies that enrolled patients without presyncope (e.g., hypoglycemia, seizure, and stroke) were excluded. We restricted our study to only English publications and searched the MEDLINE, Embase, Scopus, and Web of Science from the inception date to July 2023. We used SIGN 50 tool for assessment of risk of bias., Results: In total, 1788 articles were screened by two reviewers and 32 articles were selected for full-text assessment. Five (four prospective and one retrospective) studies with 2741 presyncope patients were included. Four studies were from North America and the fifth one was from Europe. Included studies had weaknesses due to risk of bias, but all had acceptable quality. The prevalence of overall adverse outcome varied 4.4%-26.8% for all adults and 5.5%-18.7% among older patients; arrhythmia was the most prevalent (17.4% in one study), followed by anemia/hemorrhage as reported in different studies. Among older patients, myocardial infarction was the third most common serious outcome reported in one study., Conclusions: The prevalence of short-term serious outcomes varies from 4% to 27% among ED patients with presyncope in our review, with arrhythmia being the most common serious outcome. Our review indicates that presyncope may carry a similar risk to syncope, and hence, the same level of caution should be exercised for ED presyncope management as syncope., (© 2024 The Author(s). Academic Emergency Medicine published by Wiley Periodicals LLC on behalf of Society for Academic Emergency Medicine.)

Introduction: Suspension syndrome (SS) develops when venous blood pools in extremities of passively suspended individuals, resulting in presyncopal symptoms and potential unconsciousness or death independent of additional injuries. We investigated use of leg raising to delay onset of SS, as it can decrease venous pooling and increase cardiac return and systemic perfusion., Methods: Participants were suspended in rock climbing harnesses at an indoor climbing wall in a legs-dangling control position or a legs-raised interventional position to compare physiological outcomes between groups. Participants were suspended for a maximum of 45 min. Onset of 2 or more symptoms of SS, such as vertigo, lightheadedness, or nausea, halted suspension immediately. We recorded each participant's heart rate, blood pressure, oxygen saturation, lower leg oxygen saturation, pain rating, and presyncope scores presuspension, midsuspension, and postsuspension, as well as total time suspended., Results: There were 24 participants. There was a significant difference in total time suspended between groups (43.05±6.7 min vs 33.35±9.02 min, p =0.007). There was a significant difference in heart rate between groups overall ( p =0.012), and between groups, specifically at the midsuspension time interval (80±11 bpm vs 100±17 bpm, p =0.003). Pain rating was significantly different between groups ( p =0.05). Differences in blood pressure, oxygen saturation, lower leg oxygen saturation, and presyncope scores were not significant., Conclusion: Leg raising lengthened the time individuals tolerated passive suspension and delayed symptom onset., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Cytotoxic lesion of the corpus callosum (CLOCC) stems from a variety of causes such as malignancies, drug treatments, metabolic disorders, subarachnoid hemorrhage, and infections, and often presents as encephalitis or encephalopathy. During this pandemic, we saw 2 cases with this lesion; the first one was a 42-year-old male who presented to the emergency department with complaints of headache, fever, and cough. There was a ground-glass opacity in the thorax computed tomography, and diffusion restriction was found in the corpus callosum splenium in the cranial magnetic resonance imaging (MRI) performed for headache that did not resolve with analgesic treatment during hospitalization due to the preliminary diagnosis of Coronavirus diseases-2019 (COVID-19) pneumonia. In the second case, Severe Acute Respiratory syndrome Coronavirus-2 polymerase chain reaction was found to be positive in the examinations performed during his admission to the emergency service due to weakness and presyncope, and diffusion restriction was observed in the corpus callosum splenium like the first case in cranial imaging. The follow-up cranial MRI was normal in both cases, so they were diagnosed with CLOCC. We aimed to report the present cases with COVID-19 associated CLOCC since they presented only as a headache and a presyncope without any mental deterioration. [ABSTRACT FROM AUTHOR]

Pectus excavatum (PEX) is an anterior chest wall deformity with sternal depression relative to the costal cartilages. We describe a patient status post remote PEX repair who presented with presyncope attributed to bifascicular block, partial right ventricular outflow tract (RVOT) obstruction, and right coronary artery (RCA) ischemia. Key Clinical Message: The clinician should be cognizant of the hemodynamic impact and electrocardiographic changes in a symptomatic patient status post pectus excavatum repair. [ABSTRACT FROM AUTHOR]

The proclivity to atlantoaxial instability (AAI) has been widely reported for conditions such as rheumatoid arthritis and Down syndrome. Similarly, we have found a higher than expected incidence of AAI in hereditary connective tissue disorders. We demonstrate a strong association of AAI with manifestations of dysautonomia, in particular syncope and lightheadedness, and make preliminary observations as to the salutary effect of surgical stabilization of the atlantoaxial motion segment. In an institutional review board–approved retrospective study, 20 subjects (16 women, 4 men) with hereditary connective tissue disorders had AAI diagnosed by computed tomography. Subjects underwent realignment (reduction), stabilization, and fusion of the C1-C2 motion segment. All subjects completed preoperative and postoperative questionnaires in which they were asked about performance, function, and autonomic symptoms, including lightheadedness, presyncope, and syncope. All patients with AAI reported lightheadedness, and 15 had refractory syncope or presyncope despite maximal medical management and physical therapy. Postoperatively, subjects reported a statistically significant improvement in lightheadedness (P = 0.003), presyncope (P = 0.006), and syncope (P = 0.03), and in the frequency (P < 0.05) of other symptoms related to autonomic function, such as nausea, exercise intolerance, palpitations, tremors, heat intolerance, gastroesophageal reflux, and sleep apnea. This study draws attention to the potential for AAI to present with syncope or presyncope that is refractory to medical management, and for surgical stabilization of AAI to lead to improvement of these and other autonomic symptoms. [ABSTRACT FROM AUTHOR]

Syncope and presyncope lead to well over one million emergency room visits in the United States each year. Elucidating the cause of syncope or presyncope, which are grouped together given similar etiologies and outcomes, can be exceedingly difficult given the diverse etiologies. This becomes more challenging as some causes, such as vasovagal syncope, are relatively innocuous while others, such as cardiac-related syncope, carry a significant increased risk of death. While the mainstay of syncope and presyncope assessment is a detailed history and physical examination, imaging can play a role in certain situations. In patients where a cardiovascular etiology is suspected based on the appropriate history, physical examination, and ECG findings, resting transthoracic echocardiography is usually considered appropriate for the initial imaging. While no imaging studies are considered usually appropriate when there is a low probability of cardiac or neurologic pathology, chest radiography may be appropriate in certain clinical situations. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment. [ABSTRACT FROM AUTHOR]

Purpose of Review: Cardiovascular autonomic dysfunction (AD) among cancer survivors is increasingly being recognized. However, the mechanisms and incidence are poorly understood. In this review, the clinical features, diagnostic modalities, proposed mechanisms, and currently available treatments of cardiovascular AD in cancer survivors are described. Recent Findings: Much of our current understanding of cardiovascular AD is based on disease states such as diabetes, multisystem atrophy, and Parkinson's disease. Several non-invasive tests, measurements, and scoring systems have been developed as surrogates for autonomic function, with some even demonstrating associations with all-cause mortality. The mechanism of cardiovascular AD specifically in the cancer population, however, has not been directly studied. The etiology of cardiovascular AD in cancer survivors is likely multifactorial, and proposed mechanisms include direct nerve damage by chemoradiation, the pro-inflammatory state associated with malignancy, and paraneoplastic syndromes. It may also be that cardiovascular AD is an early marker of global cardiomyopathy rather than its own condition. Current pharmacologic options for cardiovascular AD are extrapolated from how it has been treated in other disease processes, and these agents have not been studied in the cancer population or compared head-to-head. Summary: Cardiovascular AD in cancer survivors can cause significant debilitation and may be associated with all-cause mortality. Current diagnostic modalities have several limitations, such as standardization and validity. However, given the nonspecific nature of cardiovascular AD, these tools provide an objective marker for diagnosis and tracking treatment response. While the mechanism of cardiovascular AD in cancer survivors has not been directly studied, it may be useful to evoke mechanisms of cardiovascular AD in other disease states such as diabetes, Parkinson's disease, and multisystem atrophy in addition to identifying unique conditions associated with malignancy like a pro-inflammatory state. Until further studies are performed, management of cardiovascular AD as seen in other disease states may serve as a guide for symptom management in cancer survivors. [ABSTRACT FROM AUTHOR]

Introduction: Recent studies have described several cardiovascular manifestations of COVID‐19 including myocardial ischemia, myocarditis, thromboembolism, and malignant arrhythmias. However, to our knowledge, syncope in COVID‐19 patients has not been systematically evaluated. We sought to characterize syncope and/or presyncope in COVID‐19. Methods: This is a retrospective analysis of consecutive patients hospitalized with laboratory‐confirmed COVID‐19 with either syncope or presyncope. This "study" group (n = 37) was compared with an age and gender‐matched cohort of patients without syncope ("control") (n = 40). Syncope was attributed to various categories. We compared telemetry data, treatments received, and clinical outcomes between the two groups. Results: Among 1000 COVID‐19 patients admitted to the Mount Sinai Hospital, the incidence of syncope/presyncope was 3.7%. The median age of the entire cohort was 69 years (range 26‐89+ years) and 55% were men. Major comorbidities included hypertension, diabetes, and coronary artery disease. Syncopal episodes were categorized as (a) unspecified in 59.4% patients, (b) neurocardiogenic in 15.6% patients, (c) hypotensive in 12.5% patients, and (d) cardiopulmonary in 3.1% patients with fall versus syncope and seizure versus syncope in 2 of 32 (6.3%) and 1 of 33 (3.1%) patients, respectively. Compared with the "control" group, there were no significant differences in both admission and peak blood levels of d‐dimer, troponin‐I, and CRP in the "study" group. Additionally, there were no differences in arrhythmias or death between both groups. Conclusions: Syncope/presyncope in patients hospitalized with COVID‐19 is uncommon and is infrequently associated with a cardiac etiology or associated with adverse outcomes compared to those who do not present with these symptoms. [ABSTRACT FROM AUTHOR]

Aim: The tongue is a most suitable donor site for the closure of cleft palate fistulae. The aim of this prospective study was to reassess the efficacy of tongue flap technique. Patients and Methods: 4 cleft patients who underwent reconstruction by anteriorly based tongue flap between 2015 and 2017 were studied. Variables such as flap's ability to close the fistula, the remaining tongue shape at least 1 year after surgery, and speech improvement (patient's self-assessment and parents' opinion) were evaluated. Results: 4 cases presenting with type IV palatal fistulae and one type V were operated on using a double-layer closure with tongue flap. The average age at the time of the intervention was 68,5 years. The initial malformation was a complete unilateral cleft for 2 patients, and a palate velar cleft for the 2 others. The size of the fistulas was variable in length (7 to 12 mm). The procedure was successful as no recurrence of fistula was noticed at an average follow-up of 18 months, with full recovery of tongue esthetic and function. Conclusion: Tongue flaps are used in cleft palate surgery because of their excellent vascularity, and the large amount of tissue that they provide has made tongue flaps particularly appropriate for the repair of large fistulas in palates scarred by previous surgery. We recommend this as a reliable surgical technique for the closure of palatal fistulas. [ABSTRACT FROM AUTHOR]

Background Psychogenic pseudosyncope (PPS), a conversion disorder and syncope mimic, accounts for a large proportion of 'unexplained syncope'. PPS is diagnosed by reproduction of patients' symptoms during head-up tilt (HUT). Electroencephalogram (EEG), a time consuming and resource intensive technology, is used during HUT to demonstrate absence of cerebral hypoperfusion during transient loss of consciousness (TLOC). Near-infrared spectroscopy (NIRS) is a simple, non-invasive technology for continuous monitoring of cerebral perfusion. We present a series of patients for whom PPS diagnosis was supported by NIRS during HUT. Methods Eight consecutive patients with suspected PPS referred to a syncope unit underwent evaluation. During HUT, continuous beat-to-beat blood pressure (BP), heart rate (HR) and NIRS-derived tissue saturation index (TSI) were measured. BP, HR and TSI at baseline, time of first symptom, presyncope and apparent TLOC were measured. Patients were given feedback and followed for symptom recurrence. Results Eight predominantly female patients (6/8, 75%) aged 31 years (16–54) were studied with (5/8, 63%) having comorbid psychiatric diagnoses, and (5/8, 63%) presenting with frequent episodes of prolonged TLOC with eyes closed (6/8, 75%). All patients experienced reproduction of typical events during HUT. Systolic BP (mmHg) increased from baseline (129.7 (interquartile range [IQR] 124.9–133.4)) at TLOC (153.0 (IQR 146.7–159.0)) (P -value = 0.012). HR (bpm) increased from baseline 78 (IQR 68.6–90.0) to 115.7 (IQR 93.5–127.9) (P -value = 0.012). TSI (%) remained stable throughout, 71.4 (IQR 67.5–72.9) at baseline vs. 71.0 (IQR 68.2–73.0) at TLOC (P -value = 0.484). Conclusions NIRS provides a non-invasive surrogate of cerebral perfusion during HUT. We propose HUT incorporating NIRS monitoring in the diagnostic algorithm for patients with suspected PPS. [ABSTRACT FROM AUTHOR]

Background: Syncope is a common condition that may be prevented. There are non-pharmacological interventions that may be of benefit during the acute episode preceding syncope (presyncope), including physical counter-pressure maneuvers (PCM) or change of body position. We performed a systematic review of interventions that may be applied during presyncope as an immediate, first aid tactic. Methods: We searched Medline, Embase, and CINAHL and used the Grading of Recommendations Assessment, Development and Evaluation methods, and risk of bias assessments to determine the certainty of the evidence. We included randomized controlled trials (RCTs), non-randomized studies, and case series investigating adults and children with signs and symptoms of presyncope of suspected vasovagal or orthostatic origin who applied any intervention that could be used as an immediate, first aid intervention. We examined the following outcomes: prevention of syncope, adverse events, symptom improvement, and vital signs. We conducted a sub-group analysis based on the etiology of vasovagal or orthostatic presyncope. Results: We screened 5,160 titles and abstracts followed by 81 full text articles. We identified 8 studies meeting inclusion criteria, including 2 RCTs and 6 observational studies. All studies used PCM in adults and all were judged to be of low and very low certainty of evidence. For prevention of syncope, one RCT demonstrated benefit with the use of PCM (RR = 1.80 [1.26–1.89]), while observational studies failed to show benefit (RR = 1.31 [0.98 – 1.75]). Two RCTs showed benefit in symptom improvement (RR = 6.00 [2.21 – 8.61] and (RR = 1.57 [1.06 – 1.93]). Blood pressure (BP) improved with the use of PCM: systolic BP mean difference (MD) 21 mmHg higher (95% CI: 18.25 to 23.41 BPM) and diastolic BP MD 11 mmHg higher (95% CI: 9.39 to 13.10 mmHg higher). No adverse events were reported. Conclusion: While there is a minimal amount of evidence available and the findings were mixed, PCM may provide benefit for prevention of syncope during acute episodes of presyncope and may be tried in the first aid setting. No evidence was found for other non-pharmacologic interventions or for the use of PCM in children. [ABSTRACT FROM AUTHOR]

We investigated that the effects of hypercapnia-induced elevations in cerebral perfusion during a heat stress on global cerebrovascular responses to an orthostatic challenge. Seven volunteers completed a progressive lower-body negative pressure (LBNP) challenge to presyncope during heat stress, with or without breathing a hypercapnic gas mixture. Administration of the hypercapnic gas mixture increased the partial pressure of end-tidal CO2 greater than pre-heat stress alone, and increased both internal carotid artery (ICA) and vertebral artery (VA) blood flows (P < 0.05). During LBNP, both ICA and VA blood flows with the hypercapnic gas mixture remained elevated relative to the control trial (P < 0.05). However, at the end of LBNP due to pre-syncopal symptoms, both ICA and VA blood flows decreased to similar levels between trials. These findings suggest that hypercapnia-induced cerebral vasodilation is insufficient to maintain cerebral perfusion at the end of LBNP due to pre-syncope in either the anterior or posterior vascular beds. [ABSTRACT FROM AUTHOR]