Circulation, Vol 84, 1157-1164, Copyright © 1991 by American Heart Association
BP Grubb, G Gerard, K Roush, P Temesy-Armos, P Montford, L Elliott, H Hahn and P Brewster
BACKGROUND. To determine the effect of vasovagally mediated syncope on the
cerebral circulation, transcranial Doppler sonography was used to assess
changes in cerebral blood flow velocity during head-upright tilt- induced
syncope. METHODS AND RESULTS. Thirty patients (17 men and 13 women; mean
age, 43 +/- 22 years) with recurrent unexplained syncope were evaluated by
use of an upright tilt-table test for 30 minutes, with or without an
infusion of intravenous isoproterenol (1-4 micrograms/min), in an attempt
to provoke bradycardia, hypotension, or both. Transcranial Doppler
sonography was used to assess middle cerebral artery systolic velocity
(Vs), diastolic velocity (Vd), ratio of systolic to diastolic velocities,
pulsatility index (PI = Vs- Vd/Vmean), and resistance index (RI = Vs-Vd/Vs)
before, during, and after tilt. Syncope occurred in six patients (20%)
during the baseline tilt and 14 (46%) during isoproterenol infusion (total
positives, 66%). In the tilt-positive patients, concomitant with the
development of hypotension and bradycardia, transcranial Doppler sonography
showed a 75 +/- 17% decrease in diastolic velocity, unchanged systolic
velocity, a 46 +/- 17% decrease in mean velocity, a 295 +/- 227% increase
in pulsatility index, and a 73 +/- 34% increase in resistance index.
CONCLUSIONS. These findings reflect increased cerebrovascular resistance
secondary to arteriolar vasoconstriction distal to the insonation point of
the middle cerebral artery. This is paradoxic because the expected response
of the cerebral circulation to hypotension is vasodilation. We conclude
that abnormal baroreceptor responses triggered during vasovagal syncope
result in a derangement of cerebral autoregulation with paradoxic
vasoconstriction in the face of increasing hypotension.
ARTICLES
Cerebral vasoconstriction during head-upright tilt-induced vasovagal syncope. A paradoxic and unexpected response
Department of Medicine, Medical College of Ohio, Toledo 43699.
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