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*For medical professionals only
A civilization on the definition, classification, incidence and diagnosis
of orthostatic intolerance after stroke.
Organize | The healer is benevolent
At the "Expert Consensus on the Management of Cognitive Impairment after Stroke (2021 Edition) National Online Tour - Northwest Station", Professor You Yong of the Second Affiliated Hospital of Hainan Medical College brought a wonderful lecture "Pay attention to orthostatic intolerance and cerebral hypoperfusion after stroke", although orthostatic intolerance and cerebral hypoperfusion are common clinical symptoms, but there is not so much attention to their management and intervention, Professor You Yong systematically sorted out the relevant knowledge, and attached 7 real cases, full of dry goods, let's take a look~
What is orthostatic intolerance syndrome?
What are the clinical categories?
Orthostatic Intorlerance (OI) refers to recurrent or persistent symptoms and signs
caused by abnormal blood circulation in an upright position.
Usually occurs when the position changes from a sitting or lying position to an upright position, and resolves
after sitting or lying flat.
With or without orthostatic tachycardia, orthostatic hypotension, or syncope
.
Clinical symptoms consist of two parts—symptoms of orthostatic intolerance and symptoms unrelated to postural status (Table 1).
Table 1.
Clinical signs
The clinical classification can be divided into (1) acute OI (symptoms lasting ≤ 1 week); (2) subacute OI (symptoms lasting > 1 week and ≤ 3 months); (3) Chronic OI (symptoms lasting > 3 months).
From the pathogenesis type, it can be divided into: (1) orthostatic hypotension; (2) orthostatic tachycardia syndrome; (3) vasovagal syncope after standing for a long time; (4) Others, such as orthostatic hypertension
.
What is the incidence of OI in stroke patients after stroke?
Professor You Yong introduced that the famous SPS3 study included 2275 patients with lacunar infarction, with an average follow-up of 3.
2±1.
6 years, 881 (39%) patients developed orthostatic hypotension, of which 41% had OI
.
Patients with concurrent OH had a 1.
8-fold higher chance of another stroke, and ischemic stroke, major vascular events, and all-cause mortality were also higher
in the group complicated by orthostatic hypotension.
A cross-sectional study of stroke clinics in the United States (2012) showed that stroke patients with coronary syndrome or orthostatic hypotension were more likely to develop orthostatic hypotension
after stroke.
In addition, a cross-sectional study in China included 206 ischemic stroke patients, aged ≥ 60 years, 29.
61% of orthostatic hypotension occurred within 1 week after stroke, and the probability of post-stroke cognitive impairment in such patients was higher after 3 months, especially the impairment of attention, calculation and recall was more significant
.
Professor Yau added: "The study to be published by our own research team also shows that orthostatic hypotension is an independent risk factor
for stroke recurrence.
”
A 2003 study of 71 patients who began recovery within 4 weeks of their initial stroke and completed the Tilt Upright Test (HUTT) within 3 days of admission found that 52.
1% developed orthostatic hypotension, 32.
5% developed OI, and 2 developed syncope.
A 2022 study retrospectively analysed a batch of prospective data and included 3201 patients showing that 27% of stroke patients had orthostatic hypertension, and found that patients aged ≤65 years without prior hypertension had a lower risk of transient ischemic attack (TIA) if they developed orthostatic hypertension, suggesting that orthostatic hypertension after stroke may be a protective factor
for recurrent TIA in stroke patients.
Overall, the high incidence of OI after stroke requires our concern
.
Diagnostic methods for OI
Professor You Yong said that at present, comprehensive diagnosis is mainly carried out through HUTT or active lying position test combined with heart rate and blood pressure changes, and OIs of different types have different characteristics (Figure 1).
Figure 1.
Classical clinical classification of OI Note: POTS orthostatic tachycardia syndrome, OH is orthostatic hypotension, iOH is intraoperative hypotension in noncardiac surgery, VVS is vasovagal syncope
In addition, Clinicians are also experimenting with different methods, such as brain function tests during HUTT or active supine tests
.
Table 2.
Brain function tests are performed during the HUTT or active lying position test
7 cases to help you understand deeply
Case 1
Male, 60 years old, right limb weakness, slurred speech for 1 day, history
of hypertension.
Figure 2.
Images
on Day 1 (left) and Day 15 (right) At 15 days, he complained of dizziness when standing upright, unsteady standing, dare not stand and walk alone, improve when lying down, and unwilling to undergo sports rehabilitation training
.
Figure 3: Bench TCD test Therefore, arrange the patient for the recumbent TCD test
:
- Lying blood pressure and heart rate:
Blood pressure in the supine position: 98/74mmHg, heart rate: 83 beats/min;
Standing 1min blood pressure: 183/130mmHg, heart rate: 83 times/min;
Standing 3min blood pressure: 183/129mmHg, heart rate: 94 beats/min
.
- Cerebral blood flow in the lying position showed that the W wave disappeared, and it did not return to the baseline level within 2 minutes.
Impaired
brain autoregulation.
It can be found that the patient has orthostatic hypertension and impaired autoregulation, and the reason for the patient's reluctance to undergo rehabilitation training has been found
.
Fig.
4.
Thalamic stroke can lead to autonomic dysfunction, and cause abnormal blood pressure regulation
in patients with orthostatic hypertension with supine or orthostatic tilt test systolic blood pressure increase of ≥20mmHg, mostly no obvious symptoms, some patients may have dizziness, headache, palpitations, Nausea and other OI symptoms, symptoms and increased blood pressure and sympathetic hyperresponsiveness
.
In addition, orthostatic hypertension is a risk factor for cardiovascular disease and is associated with
autonomic dysfunction.
Professor You Yong pointed out that autonomic dysfunction after stroke is more common, and the main affected parts include the hypothalamus, insular lobe, brainstem, etc.
, divided into sympathetic and parasympathetic nervous systems, which can lead to abnormal heart rate variability, arrhythmia, sudden cardiac death, abnormal blood pressure regulation, baroreceptor sensitivity disorders, etc.
, which are related to poor prognosis in stroke patients, but there are few studies on orthostatic hypertension after stroke
。
Case 2
A 68-year-old man who underwent bilateral neck radiation therapy for nasopharyngeal carcinoma 12 years ago, has worsened symptoms of orthostatic intolerance since the first diagnosis of hypertension in 2014
.
Fig.
5.
The patient's course
examination showed that bilateral internal carotid artery stenosis, left MCA had changed after stenosis, MRA showed no intracranial macrovascular lesions, MRI showed white matter lesions, and no new ischemic lesions
.
Fig.
6.
The patient performed
TCD lying position test, and found orthostatic hypotension, persistent cerebral hypoperfusion, and abnormal distal cerebral vasoconstriction
.
Fig.
7.
Ambulatory blood pressure monitoring of TCD lying test
in patients found that the maximum systolic blood pressure of hypertension at night reached 180mmHg; The maximum systolic blood pressure during the day is 145mmHg, and the lowest systolic blood pressure is 90mmHg; The blood pressure can reach 80/55mmHg after 1 hour of breakfast and lunch; Heart rate 100-110 beats per minute
.
Life guidance and medication are then given:
- Slowly change position, eat small and frequent meals, take oral light saline before activity, wear elastic stockings;
- Stop taking antidepressant and anxiety medications;
- short-acting antihypertensive drugs before bedtime;
- Pay attention to monitoring blood pressure and use midodrine
as appropriate.
The patient's symptoms improved
.
Case 3
63 years old, male, right limb weakness, slurred speech with dizziness for 2 days, anterior circulation infarction, severe stenosis
of the beginning segment of the left internal carotid artery.
The lying TCD shows that the W wave on the right side is complete; The left W wave pullback is sluggish; Orthostatic intolerance score 26 points
.
Case 4
78 years old, male, left basal ganglia cerebral infarction, 70%-99% LIGA stenosis with multiple intracranial and extracranial vascular stenosis, delayed orthostatic hypotension
.
The TCD of the lying position showed that the "W" wave disappeared after the recumbent position was converted to the upright position, the upright cerebral blood flow velocity did not rebound to the baseline level, and the upright cerebral blood flow decreased progressively, and the decrease was close to 50%
when standing upright for 5 minutes.
After 2 weeks of midodrine to the upright position, the "W" wave did not appear, but the average blood flow velocity in the smooth section of the standing blood flow curve was significantly
higher than that before treatment.
Patients can be kept in a sitting position for 5-6 hours and upright for 3 hours
after half an hour of medication.
Case 5
70 years old, male, sudden dizziness, dizziness, left upper limb ataxia (+), standing tilted to the left, orthostatic lightheadedness, orthostatic hypotension after 6 days, upright tilt bed experiment (+).
Symptoms improve
with treatment.
Figure 8.
Patient imaging and TCD test results
In addition, Professor You Yong added that orthostatic hypoperfusion is a common clinical manifestation
of cerebellar infarction.
Case 6
70-year-old female, recurrent dizziness for 1 year, afraid to walk, previous history of "hypertension" for 15 years, stroke for 2 years
.
Orthostatic intolerance score is 9 points, and cerebral blood flow velocity score is 2 points
when upright.
Diagnosis: orthostatic cerebral hypoperfusion syndrome
.
Figure 9.
Patient examination data
Case 7
83-year-old male, limb weakness, shaking for more than 1 month, symptoms appear when upright, lying flat can be relieved; History of previous hypertension and stroke, mRS score of 3 before admission
.
Lying blood pressure: 156/64mmHg; heart rate 60 beats / min;
1min: blood pressure: 96/49mmHg; Heart rate: 62 beats per minute;
3min: blood pressure: 96/49mmH; Heart rate: 64 beats per minute;
5min: blood pressure: 88/55mmHg; Heart rate: 63 beats per minute;
Orthostatic intolerance score: 12 points
.
The lying TCD showed that the W wave disappeared, and dizziness appeared 1 min after standing upright; Orthostatic cerebral flow score: 5 points
.
The patient was examined 1 year after stroke, so we can find that orthostatic intolerance can occur not only during the acute stroke but also during the recovery phase
.
brief summary
Finally, Professor You Yong concluded that cardiac and cerebrovascular autonomic dysfunction has common risk factors with acute ischemic stroke, which is related to poor stroke prognosis and recurrent stroke events.
Expert profile
: You Yong
- Professor, chief physician, doctoral supervisor
- Director of the Department of Neurology and Director of the Department of Neurology of the Second Affiliated Hospital of Hainan Medical College
- Vice Chairman of the Neuroultrasound Committee of the Chinese Medical Doctor Association
- Member of the Standing Committee of the Neurodegenerative Disease Special Committee of the Chinese Microcirculation Association
- Standing member of the Youth Council of the Chinese Stroke Society
- Member of the Standing Committee of the Vascular Cognitive Impairment Professional Group of the Chinese Stroke Society
- Member of the Standing Committee of Hainan Neurology Branch
- Won the 2016 Outstanding Expert of the Brain Defense Office of the Health and Family Planning Commission
The web version of the doctor station is online, please scan the QR code below or click to read the original article, you can browse more neurological information 👇👇👇 without downloading
Audit expertYou Yong Responsible editor of the Second Affiliated Hospital of Hainan Medical CollegeMr.Submission/Reprint/Business Cooperation | Add WeChat chenaff0911
Lu Li
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