Cough syncope with hypertension—caused by brainstem compression?

Abstract

The commonly accepted pathophysiological changes in cough syncope include a fall in systemic blood pressure, raised intracranial pressure and cerebral ischemia. However, cases of cough syncope without hypotension have been reported in patients with the Arnold-Chiari malformation. We describe a 48-year old man with cough syncopes. Constant blood pressure monitoring revealed hypertension instead of the expected hypotension during the episodes. Attacks of loss of consciousness were associated with motor phenomena, i.e. tonic posturing and tonic spasm. Magnetic resonance imaging revealed compression and displacement of the medulla oblongata by an ectatic and elongated vertebral artery. The commonly accepted mechanism of cough syncope cannot explain the symptoms in our patient because a fall of blood pressure was lacking. Instead, a cough-induced compression of the displaced brainstem may have caused a transient dysfunction of the reticular formation.

Syncope due to Cervical Spine Hyperextension in Hypermobile Ehlers-Danlos Syndrome: Successful Treatment with Cranio-Cervical Stabilization: Case Report

“…Therefore, we hypothesized that the syncope of our patient is not from a classical vasovagal type [8]. We postulated that the initiation of the syncope starts in the brainstem itself, caused by distraction of fibres of the upper brainstem, inducing consequently a dysfunction of the medullar baroreceptor reflex and the midbrain reticular activating system [8][9][10]. The final purpose of the syncope is to salvage the brain's blood supply.…”