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Cough syncope with hypertension-caused by brainstem compression?

U Wieshmann1, H Meierkord

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Cough syncope typically involves low blood pressure, but this case showed hypertension. A displaced brainstem, compressed during coughing, may explain these unusual syncope episodes.

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Area of Science:

  • Neurology
  • Cardiology
  • Neuroscience

Background:

  • Cough syncope is commonly linked to a drop in blood pressure, increased intracranial pressure, and reduced cerebral blood flow.
  • Some cases of cough syncope, particularly in patients with Arnold-Chiari malformation, present without hypotension.
  • The typical mechanism involving vasovagal responses does not fully explain all presentations of cough syncope.

Purpose of the Study:

  • To describe a unique case of cough syncope presenting with hypertension and motor phenomena.
  • To investigate the underlying pathophysiology of cough syncope in a patient with an elongated vertebral artery compressing the brainstem.
  • To challenge the conventional understanding of cough syncope mechanisms.

Main Methods:

  • Continuous blood pressure monitoring during syncopal episodes.
  • Clinical assessment including detailed neurological examination.
  • Magnetic resonance imaging (MRI) of the brain to visualize anatomical structures.

Main Results:

  • The patient experienced cough syncope episodes accompanied by hypertension, not hypotension.
  • Syncopal attacks were associated with tonic posturing and tonic spasms.
  • MRI revealed an ectatic and elongated vertebral artery causing compression and displacement of the medulla oblongata.

Conclusions:

  • The patient's presentation suggests an alternative mechanism for cough syncope, involving brainstem compression rather than solely hemodynamic changes.
  • Cough-induced compression of the displaced brainstem, potentially affecting the reticular formation, may lead to transient loss of consciousness.
  • This case highlights the importance of considering structural abnormalities and brainstem compression in atypical cough syncope presentations.