Reduction in Pulse Pressure during Standing Can Distinguish Neurogenic Orthostatic Hypotension.

BACKGROUND: We investigated whether changes in the pulse pressure (PP) reduction ratio during the head-up tilt test (HUTT) can aid in distinguishing neurogenic orthostatic hypotension (OH) from non-neurogenic OH. METHODS: We enrolled consecutive patients with NOH and non-neurogenic OH between January 2015 and October 2018. We compared the Valsalva ratio, the presence or absence of late phase II and IV overshoot, the pressure recovery time, and the PP reduction ratio during HUTT between the two OH groups. RESULTS: The expiratory-inspiratory (E:I) ratio and Valsalva ratio were significantly decreased in the NOH group (p = 0.026, p < 0.001, respectively). The absence of late phase II and phase IV overshoot was more frequent in the NOH group than in the non-neurogenic OH group (p = 0.001, p < 0.001, respectively). The pressure recovery time was significantly prolonged in the NOH group (p < 0.001), which exhibited increases in the PP reduction ratio (1-minimal PP/baseline PP) during the HUTT (p < 0.001). We calculated the cutoff point for the PP reduction ratio during HUTT, which exhibited an area under the receiver operating characteristic curve of 0.766 (0.659-0.840, 95% confidence interval). The cutoff value for the PP reduction ratio during HUTT (0.571) exhibited sensitivity of 0.879 and specificity of 0.516. CONCLUSIONS: Increases in the PP reduction ratio during HUTT may be a meaningful NOH laboratory marker.

Quantitative autonomic function test in differentiation of multiple system atrophy from idiopathic Parkinson disease.

BACKGROUND: Differential diagnosis of idiopathic Parkinson disease (IPD) and multiple system atrophy-Parkinson type (MSA-P) is challenging since they share clinical features with parkinsonism and autonomic dysfunction. To distinguish MSA-P from IPD when the symptoms are relatively mild, we investigated the usefulness of the quantitative fractionalized autonomic indexes and evaluated the correlations of autonomic test indexes and functional status. METHODS: Thirty-six patients with parkinsonism (22 with IPD and 14 with MSA-P) in Soonchunhyang University Bucheon Hospital from February 2014 to June 2015 were prospectively enrolled in the study. We compared fractionalized autonomic indexes and composite autonomic scoring scale between patients with IPD and MSA-P with Hoehn and Yahr (H&Y) score ≤3. Parasympathetic indexes included expiratory/inspiratory ratio during deep breathing, Valsalva ratio (VR), and regression slope of systolic blood pressure (BP) in early phase II (vagal baroreflex sensitivity) during Valsalva maneuver. Sympathetic adrenergic indexes were pressure recovery time (PRT) and adrenergic baroreflex sensitivity (BRSa) (BP decrement associated with phase 3 divided by the PRT), sympathetic index 1, sympathetic index 3, early phase II mean BP drop, and pulse pressure reduction rate. Additionally, we compared the unified multiple system atrophy rating scale (UMSARS) and H&Y scores and the autonomic indexes in all patients. RESULTS: PRT was significantly different between the IPD and MSA-P groups (P = 0.004) despite the similar BP drop during tilt. Cut-off value of PRT was 5.5 s (sensitivity, 71.4%; specificity, 72.7%). VR (r = -0.455, P = 0.009) and BRSa (r = -0.356, P = 0.036) demonstrated a significant correlation with UMSARS and H&Y scores. CONCLUSIONS: Among the cardiovascular autonomic indexes, PRT can be a useful parameter in differentiating the early stage of MSA-P from that of IPD. Moreover, VR, and BRSa may be the optimal indexes in determining functional symptom severity.

Transient Anarthria and Quadriplegia in a Patient with Basilar Artery Hypoplasia and Coincidental Intracranial Lipoma: A Case Report.

Cerebral ischemia may be rarely associated with a hypoplastic vertebrobasilar system. Intracranial lipoma is also a very rare congenital malformation. We report the case of a 52-year-old woman with vertebrobasilar transient ischemic attack associated with basilar artery hypoplasia and coincidental intracranial lipoma. She presented with sudden-onset dizziness, anarthria, and quadriplegia lasting for about 30 min. The patient's initial blood pressure was measured at 200/120 mm Hg. The magnetic resonance and computed tomographic images showed the absence of an acute ischemic lesion in the brain but revealed a hypoplasia of the basilar artery and bilateral V4 vertebral arteries. A lipoma of 11 mm in long diameter was also found in the quadrigeminal cistern and at the superior vermis. The electroencephalography, transthoracic echocardiogram, 24-h Holter monitoring, and transcranial Doppler ultrasonography, including patent foramen ovale study, were all noted as negative. The patient was treated with oral aspirin 100 mg, atorvastatin 10 mg, and antihypertensive medication. She had no symptom recurrence after the treatment. Our case suggests that hypoplasia of the vertebrobasilar arteries can be a predisposing factor for posterior circulation ischemia, especially when additional vascular risk factors coexist.