Long-term EKG monitoring in patients with cerebrovascular insufficiency.

Abstract

SUMMARY Cardiac dysrhythmia may be responsible for signs of cerebrovascular insufficiency in some patients. Ten patients with cerebrovascular insufficiency were monitored for up to 24 hours with the Holter EKG monitor. Eight of the patients had transient ischemic attacks and two had mild deficits from a completed stroke. Eight of the ten patients had associated abnormal cerebral angiography, the most frequent finding being carotid stenosis. Holter EKG monitoring in these ten patients showed no abnormalities in four patients. The remaining six had a variety of cardiac dysrhythmias. Although there were a variety of cardiac, cerebrovascular, and neurological abnormalities in these ten patients, six of these patients had a disturbance in cardiac rhythm or conduction which could have been directly associated with or suggest an etiology for the patient's neurological event.CORDAY et al.1 -2 and others 3 7 have emphasized that cardiac dysrhythmias may affect the cerebral circulation. As Corday et al.2 pointed out, more than 50% of patients with cardiac dysrhythmias are not aware of a dysrhythmia and they may present to the physician with neurological manifestations or with symptoms of coronary insufficiency. Barnes 3 asserted that weakness, vertigo, nervousness, insomnia, and even syncope may occur. Such generalized symptoms of cerebral ischemia may be more frequent than realized. Corday et al.1 emphasized that rapid cardiac dysrhythmias are apt to induce sufficient reduction in cerebral perfusion to cause cerebral ischemia. If cerebral artery narrowing from atherosclerosis or kinking is also present, it is entirely possible that the collateral circulation to a vital area of the brain will fail because of a reduced head of pressure and blood flow. Sulg et al. 8 and Shapiro et al. 9 have demonstrated in man that cardiac dysrhythmias may significantly reduce cerebral blood flow (CBF). Recently, McAllen and Marshall' described patients with cardiac dysrhythmia with transient ischemic attacks (TIAs). They considered that the possibility of TIAs being due to cardiac dysrhythmias seemed to be insufficiently appreciated. As suggested by Corday et al., 2 the introduction of the Holter monitor 10 allows one to monitor patients to detect transient dysrhythmias that may be associated with generalized or focal neurological symptoms. The purpose of this report is to describe ten patients with cerebrovascular insufficiency who had long-term Holter electrocardiographic monitoring for the detection of cardiac dysrhythmia associated with cerebrovascular symptoms. MethodsNine patients were admitted to the Neurology Service of the North Carolina Baptist Hospital because of neurological symptoms suggestive of cerebrovascular insufficiency. One additional patient was admitted because of two episodes of syncope. As well as complete physical, neurological, and neurovascular examinations, aorta-cervical-cranial angiography was performed in each case. Similarly, up to 24-hour Holter EKG monitoring 10 was carried out in each patient to Sup...

Cardiac arrhythmias in acute stroke.

“…The remaining 2 patients who were described as having transient ischemic attacks had symptoms equally well explained on the basis of global ischemia. In the study of McHenry et al 7 6 of 10 patients with cerebral ischemic symptoms had cardiac arrhythmias and 8 had angiographic proof of significant cerebrovascular disease. The arrhythmias ranged from ventricular ectopics to intraventricular conduction defects and it was suggested that these cardiac abnormalities could account for the neurological event.…”

“…At the present time there is available a non-invasive method to measure regional cerebral blood flow. This was originally described by Mallett and Veall Corbett and Eidelman, 6 and by Meyer et al 7 Normal values as well as test-retest results were described by Blauenstein and his associates. 8 The background of the xenon-inhalation method has been discussed by Merory et al 9 and Meyer et al 7 ' 10 The purpose of this paper is to report the results of regional cerebral blood flow measurements by the xenon inhalation method in normal individuals and to test the reproducibility of the method by serial measurements.…”

Management of patients with established ("completed") cerebral infarction.

“…Two studies, however, have shown that vasodilator response was reduced or impaired in only 25% of patients with cerebral circulatory disturbances." 7 ' m Mathew et al 101 noted, in 6 patients with recent hemispheric infarction, that CBF was increased in all regions after CO 2 inhalation. It is generally agreed that the steal response occurs only during the acute stages of severe and extensive cerebral infarction, and then only rarely.…”

“…It has been suggested that an osmolar gradient of about 30 mOsm is desirable for achieving an adequate dehydrating action; 79 ' u * yet the improvement in hemispheric 1 " or regional 125 blood flow is noted at 14-20 mOsm. Dehydrating agents have also been criticized as having only short-lived efficacy, 7 ' 1 "' but Newkirk et al 1 " were able to demonstrate control of intracranial pressure continuously for 3 weeks using oral glycerol.…”

Holter monitoring in patients with transient focal cerebral ischemia.

“…6 ' 7 Several authors have alluded to the role of a diminished cardiac output in various dysrhythmias as an etiologic agent in transient focal cerebral ischemia and the need for continuous ECG monitoring in these patients. 8 ' 9 Others have stressed the rarity of transient focal cerebral events in dysrhythmias associated with a significant reduction in cardiac output. 10 A recent experience with a patient who had significant cardiac dysrhythmias and transient focal cerebral ischemic symptoms which did not abate after cardiac pacing prompted a review of Holter monitoring results in patients with such transient focal cerebral symptoms.…”