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• W1520367132 abstract "To the Editor: Carotid sinus syndrome (CSS) is found in up to one-third of older patients presenting with unexplained falls.1 CSS is diagnosed when carotid sinus massage elicits a drop in systolic blood pressure of more than 50 mmHg, asystole of longer than 3 seconds, or both; this procedure is safe in older patients.2 How CSS may lead to syncope outside test settings is still a matter of debate.3 Wearing a tight collar, shaving, or turning the head are suggested to be eliciting factors, although to the authors' knowledge, evidence of this has never been published. The present case clearly illustrates how merely looking sideways may be a sufficient cause for syncope. A healthy 70-year-old woman participated in research in our department. She had been treated for hypertension in the past but was currently not taking any medication. She had never smoked and consumed alcohol with moderation. There were no abnormalities on physical examination, and her electrocardiogram (ECG) showed normal sinus rhythm. Carotid ultrasonography gave no evidence of atherosclerotic plaques or stenosis. It was noted that the left internal carotid artery had a marked tortuous trajectory, although flow patterns over both carotid arteries and both middle cerebral arteries (using transcranial Doppler) were symmetrically normal. She underwent the following test protocol in the morning, after an overnight fast, in a quiet, cool room, wearing a loose-fitting shirt. Beat-to-beat blood pressure (BP) and single-lead ECG were recorded using the Finometer (Finapres Medical Systems, Amsterdam, the Netherlands). After 10 minutes of supine rest, mean BP±standard deviation during the last minute was 178±7 mmHg systolic, 79±4 mmHg diastolic; heart rate was 62±2 beats per minute (bpm). Upon standing, BP dropped to 119 mmHg systolic; mean BP during the 5-second nadir was 124±4 mmHg systolic, 63±3 diastolic, and heart rate was 83±1 bpm. The subject was asymptomatic, and BP recovered quickly. After 1 minute of stable BP (165±4 mmHg systolic, 86±2 diastolic, heart rate 77±2 bpm), the subject was asked to look to her right. BP decreased to 124 mmHg systolic, with mean BP during the 5-second nadir 127±4 mmHg systolic, 67±1 diastolic, with heart rate 74±2 bpm. After 1 minute of stable BP (167±5 mmHg systolic, 87±3 mmHg diastolic, heart rate 82±2 bpm), she was asked to look to her left. BP now decreased to 70 mmHg systolic, and heart rate briefly dropped to 40 bpm immediately after turning the head. Mean BP during the 10-second nadir was 73±3 mmHg systolic, 42±2 mmHg diastolic, and heart rate was 70±4 bpm. At this time, she complained of transient fatigue and light-headedness. After hemodynamic stabilization, carotid sinus massage was performed in the supine position. On the right side, BP fell 40 mmHg, after brief bradycardia of 40 bpm. On the left side, BP decreased 33 mmHg after brief bradycardia of 45 bpm. This case illustrates three important points. First, evidence is presented for the first time that a turn of the head to look sideways can contribute to syncope in a patient with CSS. In this subject, BP fell 94 mmHg. This is sufficient to diagnose CSS of the vasodepressor type. A possible explanation for the greater sensitivity of the carotid sinus on the left side than on the right is the observed variant anatomy of the internal carotid artery. Second, this case represents a healthy, community-dwelling subject without a history of falls or syncope, in whom CSS was diagnosed by chance. A population study in healthy volunteers found CSS in four of 32 participants.4 Apparently, CSS is asymptomatic in certain affected individuals. The third point illustrates this. Despite severe reductions in BP during standing, head turning, and carotid sinus massage, this subject was only symptomatic when her BP fell almost 100 mmHg. This means that adequate or even improved dynamic cerebral autoregulation was able to prevent cerebral hypoperfusion and thus syncope, explaining her complete lack of symptoms in everyday life. Francien Meijerink-Jannink, RN, performed the test protocol. She also identified the effects of head turn on blood pressure during previous tests in our laboratory. Financial Disclosure: Jurgen Claassen has no previous or current financial support for research and no other financial disclosures to report. René Jansen currently has no financial support for research and no previous financial support pertaining to this investigation; no other financial disclosures to report. Author Contributions: Jurgen Claassen conceived the study design, acquired subjects and data, analyzed and interpreted data, and prepared the manuscript. René Jansen conceived study design, reviewed the data, and is senior research mentor for the first author. Sponsor's Role: None." @default.
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• W1520367132 date "2006-01-01" @default.
• W1520367132 modified "2023-10-01" @default.
• W1520367132 title "CAROTID SINUS SYNDROME: LOOKING SIDEWAYS IS SUFFICIENT CAUSE FOR SYNCOPE" @default.
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• W1520367132 doi "https://doi.org/10.1111/j.1532-5415.2005.00575_17.x" @default.
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