| Low Blood
Pressure Abstract IV
Neurally Mediated Hypotension: Its Surgical Evaluation, Management and
Early Outcome as Part of the Fibromyalgia—Chronic Fatigue Syndrome
Michael J. Rosner, MD, Peter D’Amour, MD and Peter C. Rowe, MD
INTRODUCTION: Correlation of MR findings in those
patients with FMS and CF-IDS is difficult, in part due to wide variations
in the population carrying these diagnoses. Because the subset of patients
with NMH is rigorously defined by tilt table and other objective abnormalities
and also may carry the diagnosis of FMS and/or CF-IDS, we analyzed their
clinical symptoms, signs and MR findings. The latter was especially of
concern since the radiological confirmation of structural disease in the
FMS CF-IDS population is often vague, elusive and has significant overlap
with asymptomatic patients.
METHODS: Patients referred for potential surgical
treatment with tilt table proven Neurally Mediated Hypotension (NMH) underwent
a standardized interview, neurological evaluation, magnetic resonance
(MR) evaluation including CINE MR of the posterior fossa. They also completed
a 75 item questionnaire which rated the degree of a spectrum of complaints
on a 0-3 scale (0=none, 3=severe) or a visual analog scale with 100 being
the most severe possible degree.
RESULTS: Fifteen patients have been evaluated;
eleven have undergone craniovertebral decompression; two await surgery:
- All patients have had resolution of syncope and hypotension. One remains
on a low dose of fludrocortisone and a second on a low dose of dexadrine.
- POTS has also improved or resolved in all cases, but the rate of resolution
of the POTS has been slower than that of the NMH. There seems to be
a phase of increased sensitivity to endogenous catecholamine release,
which also resolves with time. Deconditioning, which is prominent in
these patients, may also cause tachycardia, etc., and be confused with
symptoms of POTS.
- Concomitant symptoms of FMS and/or CF-IDS resolve in parallel with
normalization cardiovascular responses. These symptoms include cognitive
dysfunction, pain syndromes and a broad array of dysautonomic problems.
| Complaint
|
Pre-Op
(n=13) |
|
|
Post-Op
(n=5) |
|
|
Control
(n=6) |
|
|
|
|
| |
Mean
|
SD
|
Median
|
Mean
|
SD
|
Median
|
Mean
|
SD
|
Median
|
Profuse
Sweat |
1.6
|
(1.1)
|
[1.5]
|
1.0
|
(0.8)
|
[1]
|
0.0
|
(0.0)
|
[0]
|
|
Dizziness
|
2.2
|
(0.9)
|
[2.5]
|
1.4
|
(1.1)
|
[1]
|
0.0
|
(0.0)
|
[0]
|
|
SOB
|
1.6
|
(1.1)
|
[2.0]
|
1.0
|
(1.4)
|
[0]
|
0.0
|
(0.0)
|
[0]
|
|
Chest
Pain |
1.4
|
(1.2)
|
[1.0]
|
0.4
|
(0.9)
|
[0]
|
0.0
|
(0.0)
|
[0]
|
|
Palpitations
|
1.1
|
(1.1)
|
[1.0]
|
0.2
|
(0.4)
|
[0]
|
0.0
|
(0.0)
|
[0]
|
|
Color
Changes |
1.4
|
(1.3)
|
[2.0]
|
0.8
|
(0.8)
|
[1]
|
0.0
|
(0.0)
|
[0]
|
|
Overall
(0-3) |
1.6
|
(1.0)
|
[1.8]
|
1.1
|
(1.0)
|
[0.7]
|
0.0
|
(0.0)
|
[0]
|
| |
|
|
|
|
|
|
|
|
|
|
Days
Felt Good |
0.6
|
(0.9)
|
[0]
|
4.0
|
(4.2)
|
[3]
|
6.8
|
(0.4
) |
[7]
|
|
Missed
Work |
5.8
|
(2.0)
|
[7]
|
3.2
|
(2.2)
|
[3]
|
0.0
|
(0.0)
|
[0]
|
| |
|
|
|
|
|
|
|
|
|
|
Visual
Analog (%) |
|
|
|
|
|
|
|
|
|
Pain
Interferes |
88
|
(13)
|
[90]
|
57
|
(29)
|
[48]
|
3
|
(16)
|
[8.1]
|
|
Severity
of Pain |
78
|
(25)
|
[91]
|
48
|
(21)
|
[47]
|
1
|
(17)
|
[2.2]
|
|
Tiredness
|
91
|
(9)
|
[92]
|
69
|
(29)
|
[64]
|
10
|
(17)
|
[17]
|
|
Awaken
Rested |
93
|
(9)
|
[96]
|
67
|
(31)
|
[57]
|
32
|
(16)
|
[36]
|
- The MR differences between the patients with NMH vs. a group of normal
control patients related to the craniovertebral junction region. The
foramen magnum was smaller, 35.5 ± 2.7 vs. 39 ± 4.8, p<0.03)
and the vertebral vessels impacted the brainstem to a greater degree
and more often than controls ((p<0.03). The cerebellar tonsils were
lower, 2.0 ± 1.1 vs. 1.25 ± 1.1 (p=0.14), and the C2 canal
was smaller, 11.3 ± 4.3 v s. 13.6 ± 1.7 (p=0.07); the
latter two differences could have been due to chance.
- No patient with NMH/POTS had a normal neurological exam. Neurological
signs also improved following craniovertebral surgery.
CONCLUSIONS:
A population of patients with NMH/POTS responds to suboccipital craniectomy
and/or cervical laminectomy.
If patients carry the diagnosis of FMS or CF-IDS, then these symptoms
also resolve in parallel with the cardiovascular symptoms of NMH/POTS
following craniovertebral decompression.
The MR/radiographic appearance of these patients is characterized by
minimal abnormality and can easily be read as “normal.” However,
the essential findings are consistent with the hypoplastic posterior fossa
and/or congenital-cervical stenosis. There is, as yet, no pathognomonic
radiographic change, which allows diagnosis independently of a careful
and thorough history and physical examination.
While the radiological diagnosis of the hypoplastic posterior fossa can
be difficult, the clinical outcome after decompressive surgery warrants
a thorough evaluation and aggressive surgical approach.
Presented at the National Fibromyalgia Research Association's Subgroups
in Fibromyalgia Symposium, September 26-27, 1999, in Portland,
Oregon.
National Fibromyalgia Research Association
PO Box 500, Salem, OR 97308
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