Management of neurogenic orthostatic hypotension in patients with autonomic failure

The maintenance of blood pressure in the upright position requires intact autonomic cardiovascular reflexes. Diseases that affect the sympathetic innervation of the cardiovascular system result in a sustained fall in blood pressure upon standing (i.e., neurogenic orthostatic hypotension) that can impair the blood supply to the brain and other organs and cause considerable morbidity and mortality. Here we review treatment options for neurogenic orthostatic hypotension and include an algorithm for its management that emphasizes the importance of non-pharmacologic measures and provides guidance on pharmacologic treatment options.

Occipital nerve stimulation in the treatment of medically intractable SUNCT and SUNA

BACKGROUND

Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) or with cranial autonomic symptoms (SUNA) are primary headaches characterized by frequent attacks of severe headaches in association with cranial autonomic features. Patients with chronic SUNCT or SUNA have unremitting symptoms that necessitate prolonged use of medical preventive treatments, many of which are prone to causing side effects. They can be medically intractable, in which case neurally destructive or cranially invasive surgical treatments can be offered, though these have hitherto yielded conflicting results. Occipital nerve stimulation (ONS) offers a nondestructive and relatively low risk surgical alternative.

OBJECTIVE

To assess the efficacy and safety of ONS in chronic, medically intractable SUNCT and SUNA patients.

STUDY DESIGN

Prospective open-label study.

METHODS

Nine medically intractable, chronic SUNCT and SUNA patients were implanted with electrodes for bilateral occipital nerve stimulation. Data were collected prospectively for pre- and postimplantation headache characteristics, including frequency, intensity and duration of attacks. Diaries were used to assess headache improvement.

RESULTS

At a median follow-up of 38 months (range 24-55 months), all but one patient reported substantial improvement. Four patients became pain-free, 3 were almost pain-free (96 - 98% improvement), and one had a marked reduction in attack frequency and severity (81% improvement). After an initial rapid improvement, the maximum benefit of ONS was attained after a lag of a few months. Device malfunction was followed by recurrence or worsening of the attacks within a few days in most patients. Adverse events included lead migration, exposure of the electrode, and pain due to muscle recruitment over the leads. One patient developed hemicrania continua one month after implantation and was successfully treated with indomethacin.

CONCLUSION

ONS appears to offer an effective and safe treatment option, without significant morbidity, for medically intractable SUNCT and SUNA. Given the variable results with cranially invasive or neurally destructive surgery, ONS might be considered the surgical treatment of choice for medically intractable SUNCT and SUNA.

[Sanatorium care in autonomic nervous system disorders]

OBJECTIVE

To explore a role, place and effectiveness of different therapeutic methods in sanatorium care.

MATERIAL AND METHODS

We compared volume and structure of therapeutic methods of treatment of autonomic nervous system disorders in 571 patients of a neurological sanatorium and 924 patients of a cardiologic sanatorium.

RESULTS AND CONCLUSION

The actual volume and structure of the therapeutic methods in sanatoriums differed from republican standards. This can be explained by the aspiration of physicians to individualize treatment. Treatment outcome was correlated with the volume and structure of therapeutic methods. Sensitivity, specificity and predictive value of some methods were defined. Barotherapy, oxygen influence and psychotherapy predicted the effectiveness of different therapeutic methods in sanatorium care of patients with autonomic nervous system disorders.

[Autonomic neuropathy--a problem of the circulatory system and digestive tract]

An autonomic disorder of the circulatory system becomes manifest as aberrant heart rate variability and baroreflex sensitivity already years before progressing into symptomatic disease, in which case the condition is no longer curable. Diagnosis is based on tests of autonomic nervous system function. The main thing in the treatment is management of risk factors of cardiovascular diseases in addition to enhanced glucose homeostasis. Autonomic neuropathy may also affect the digestive tract and be accompanied by esophageal motility disorder, gastroparesis, diarrhea, constipation or fecal incontinence. It is essential in the diagnosis to exclude other diseases of the digestive tract.

Diabetic neuropathy

Diabetic neuropathy (DN) is the most common and troublesome complication of diabetes mellitus, leading to the greatest morbidity and mortality and resulting in a huge economic burden for diabetes care. The clinical assessment of diabetic peripheral neuropathy and its treatment options are multifactorial. Patients with DN should be screened for autonomic neuropathy, as there is a high degree of coexistence of the two complications. A review of the clinical assessment and treatment algorithms for diabetic neuropathy, painful neuropathy, and autonomic dysfunction is provided.

[Features of neurohumoral regulation in children with combined dysfunction of the pelvic organs]

During examination of 165 children aged 5 to 15 years (primarily identified during planned monitoring in Petrozavodsk children's institutions) with dysfunctional urination and encopresis without organic lesion of the central nervous system, autonomic dysfunction syndrome (ADS) was revealed. According to the results of urological examination, which was supplemented with the registration of spontaneous voiding rate and counting the radial pulse, overactive bladder syndrome and insufficient relaxation of the pelvic floor muscles during urination and defecation were detected; relationship between the number of heart rate (as a marker of sympathetic nervous system activity) and the effective volume was identified. It was revealed that the children with ADS in the presence of tachycardia show intermittent decrease of effective amounts of urination, and have residual urine. The standard course of treatment using colon hydrotherapy and biofeedback to activate cystic and obturator reflex caused a positive but short-term therapeutic effect; clinically and statistically significant increase in the effective volume of the bladder was not achieved, despite the reduction in residual urine volume. During the course of treatment using methods of biofeedback, bladder volume remained almost unchanged and tachycardia persisted, indicating the continued oppression of the sympathetic activity. The course of treatment using nootropic drug picamilon and alpha-adrenoblocker doxazosin with peripheral actions allowed to restore the reservoir and evacuation functions of the bladder, to achieve a regular bowel movement without encopresis. It was revealed that the combined dysfunction of pelvic organs occur in children with high activity of the sympathetic division of the ANS, which has a direct impact on the accumulation phase of voiding cycle and relaxation of the pelvic floor muscles.

The role and management of sympathetic overactivity in cardiovascular and renal complications of diabetes

Feedback activation of neurohormonal pathways in the setting of kidney or heart failure contributes to the development and progression of dysfunction in the other. Diabetes and its management independently activate these same pathogenic pathways, feeding into this vicious cycle and contributing to a poor prognosis. One of the most important of these neurohormonal pathways is the sympathetic nervous system (SNS). The activity of the SNS in increased in patients with chronic kidney disease, even in the absence of renal impairment or heart failure. There is a strong relationship between SNS overactivity and prognosis, and evidence that blockade of SNS reduces morbidity and mortality in patients with diabetes. However, modulation of SNS is underutilised as a strategy to protect both the diabetic kidney and the heart. This is partly because of the historically poor tolerability, adverse haemodynamic and metabolic effects, lack of selectivity of β-blockers and the lack of specificity of other interventions that might modify SNS activation. The advent of "vasodilating β-blockers" with better tolerability as well as more favourable effects on renal function and metabolic profiles opens the door for their more widespread utility in patients with diabetes. Radiofrequency renal sympathectomy and baroreflex activation technologies also offer exciting new ways to tackle the challenge of sympathetic overactivity.

[Acute pandysautonomia and nicotinic acetylcholine receptor antibodies]

Acute pandysautonomia is an idiopathic, acute or subacute autonomic neuropathy, which diffusely affects pre- and post-synaptic, and sympathetic and parasympathetic nerves. The recent discovery of serum autoantibodies against the nicotinic acethylcholine receptor (nAChR) on autonomic ganglia has led to a better understanding of its pathogenesis as well as the emergence of a new disease entity named autoimmune autonomic ganglionopathy (AAG). Based on the detection of these antibodies in various dysautonomic conditions, AAG is considered a broad-spectrum disease entity that includes acute pandysautonomia as well as secondary autonomic neuropathy, restricted forms of dysautonomia (postural tachycardia syndrome and chronic intestinal pseudoobstruction), and chronic dysautonomia, mimicking pure autonomic failure. Reproduction of experimental AAG animals by active immunization with peptides derived from ganglionic nAChR or passive transfer of ganglionic nAChR antibodies strongly indicates that ganglionic nAChR antibodies are pathogenic in AAG development. There are no controlled treatment trials for AAG, and its optimal therapy remains uncertain. Recent reports suggest that combined immunotherapies using immunosuppressive agents with plasma exchange or intravenous immunoglobulin are effective for some intractable cases. An optimal protocol of combined immunotherapies should be established in controlled clinical trials in the future.

Efficacy of deep brain stimulation of the subthalamic nucleus on autonomic dysfunction in patients with Parkinson's disease

Subthalamic nucleus (STN) deep brain stimulation (DBS) is well established for the treatment of the motor symptoms of Parkinson's disease (PD). However, the effect of STN DBS on autonomic symptoms has not been well studied. We examined 19 patients undergoing STN DBS for PD. The patients were administered a questionnaire to evaluate the pre-operative and post-operative autonomic function. All patients reported a significant post DBS improvement of one or more symptoms of the autonomic dysfunction (urinary and gastrointestinal function). In particular, we have shown the most significant improvement in the urinary function after STN DBS. Further larger studies are required with respect to the effect of STN DBS on the autonomic function.

The autonomic effects of deep brain stimulation--a therapeutic opportunity

Deep brain stimulation (DBS) is an expanding field in neurosurgery and has already provided important insights into the fundamental mechanisms underlying brain function. One of the most exciting emerging applications of DBS is modulation of blood pressure, respiration and micturition through its effects on the autonomic nervous system. DBS stimulation at various sites in the central autonomic network produces rapid changes in the functioning of specific organs and physiological systems that are distinct from its therapeutic effects on central nervous motor and sensory systems. For example, DBS modulates several parameters of cardiovascular function, including heart rate, blood pressure, heart rate variability, baroreceptor sensitivity and blood pressure variability. The beneficial effects of DBS also extend to improvements in lung function. This article includes an overview of the anatomy of the central autonomic network, which consists of autonomic nervous system components in the cortex, diencephalon and brainstem that project to the spinal cord or cranial nerves. The effects of DBS on physiological functioning (particularly of the cardiovascular and respiratory systems) are discussed, and the potential for these findings to be translated into therapies for patients with autonomic diseases is examined.

Nonlinear Analysis of Heart Rate Variability During Qi Therapy (External Qigong)

Heart rate variability (HRV) was compared in 30 subjects receiving external Qi therapy (EQT) or placebo control therapy, in a crossover design experiment. Subjects who received the EQT reported more pleasant and calm emotions than did the placebo group. Qi therapy reduced the heart rate and increased HRV as indicated by a reduced low frequency/high frequency power ratio of HRV. With nonlinear analysis, the Poincaré plot index of HRV and approximate entropy was greater in the EQT group than in the control group. These findings suggest that EQT stabilizes the sympathovagal function and cardiac autonomic nervous system by inducing more positive emotions than the placebo therapy. In conclusion, EQT may act by stabilizing both the autonomic nervous system and the emotional state.

Managing systemic symptoms in chronic liver disease

Improved medical management and the changing disease demographic mean that the majority of patients with chronic liver disease are living with the disease rather than dying from it. Historically, the perception has been that the impact of chronic liver disease is related entirely to the consequences of endstage liver disease; however, more recently a number of systemic symptoms have been recognised that can occur at any point in the natural history of chronic liver disease and which can be associated with functional impairment and reduced quality of life. The most characteristic of these systemic symptoms is fatigue, which frequently associates with sleep disturbance and autonomic dysfunction, particularly manifest as abnormality of blood pressure regulation. Cognitive symptoms can occur even in non-cirrhotic patients. Falls can present in patients with autonomic dysfunction, complicated by the presence of peripheral muscle strength problems. Importantly for clinicians managing chronic liver disease, the severity of these systemic symptoms is typically not related to liver disease severity, and therefore despite optimal liver disease management, patients can often continue to experience debilitating symptoms. The similarity in systemic symptoms between different chronic liver diseases (and indeed chronic inflammatory conditions affecting other organs) suggests the possibility of shared pathogenetic processes and raises the possibility of common management strategies, although further research is urgently needed to confirm this. In primary biliary cirrhosis, where our understanding of systemic symptoms is arguably most developed, structured management strategies have been shown to improve the quality of life of patients. It is highly likely that similar approaches will have comparable benefits for other chronic liver disease groups. Here, we review the current understanding of systemic symptoms in chronic liver disease and offer recommendations regarding the successful management of these symptoms. Critical for successful treatment is use of a structured and systematic approach to management in which all contributing factors are addressed in an organised fashion. We believe that such a systematic approach, when applied to research as well as to clinical management, will allow us to reduce the overall burden of chronic liver disease, improve quality of life and enhance functional ability.

[The effect of ozone therapy on the activity of the autonomic nervous system]

We studied 48 patients, mean age 57 years, 14 men, 34 women, with chronic cerebrovascular disease and autonomic dysfunction. Patients had different types of autonomic response (sympathicotonic or normotonic). Autonomic tone at baseline, autonomic reactivity and autonomic supply of activity were determined. Patients were divided into 2 groups. Patients of the main group received ozone therapy along with standard medications. Patients of the control group received standard medications. Disturbances of vascular-autonomic regulation with the domination of ergotropic sympathetic effects were identified in 69.7% of patients with chronic cerebrovascular disease. Ozone therapy caused a shift of the autonomic balance towards the parasympathetic activity as well as the decrease in the activity of the vasomotor center and the central regulation circuit that indicates the increase in the power of defense mechanisms associated with the normalization of autonomic balance.

[Mental and autonomic disorders in children and adolescents with diabetes mellitus type I and their correction using color and rhythm therapy]

The objective of the study was to work out a method of color and rhythm therapy (CRT) for correction of mental and autonomic disorders in children with diabetes mellitus type I. The elaboration of the method was based on the results of examination of 62 patients, aged 7-16 years. In addition, a psychometric assessment of anxiety (the Spielberger-Khanin test), stress resistance and communicative abilities (the Luscher color test), depression (the scale of Saint-Petersburg Bekhterev's Psychoneurological Research Institute) and autonomic dysfunctions (the Vein's questionnaire) was performed. CRT was conducted with the apparatus"Color-rhythm" that allows to perform stimulation with the light of specified length. The high effectiveness of CRT in the correction of mental and autonomic disorders depending on the character of disorders and effects of separate photic stimuli (red or yellow, green and blue), sequence and rhythm of their presentation is demonstrated. The choice of automatic working regime of the apparatus is proved to be optimal.

[Mental, autonomic and neurophysiological disturbances in patients with obesity and their treatment with transcranial stimulation]

Authors studied 85 patients, aged from 45 to 68 years, suffered from obesity (stage I and stage II) for more than 5 years with concomitant arterial hypertension and atherosclerosis. Patients were randomized into two groups. Patients of the main group received transcranial stimulation (TS) along with standard treatment with antiaggregant vascular drugs and hypocaloric diet. Patients of the control group received placebo TS procedures with turned-off electrodes. The TS treatment was carried out using frontal-mastoid recording with the by-turn stimulation of the right and left hemispheres (frequency = 10Hz, number of daily sessions = 10-12). Psychometric scales, rhythmocardiography, EEG and evaluation of lipid peroxidation activity were used to assess the patient's status. Positive changes for most of the parameters used in the study were noted in the main group compared to the control one. The body-mass index was decreased by 9.8% in the main group.

The impact and management of nonmotor symptoms of Parkinson's disease

Parkinson's disease (PD) is a common neurodegenerative disorder diagnosed by the presence of bradykinesia and at least 1 of the symptoms of rigidity, resting tremor, or postural instability. It is increasingly recognized that nonmotor symptoms are common and can adversely affect quality of life, yet they often are not diagnosed and consequently are often untreated. Nonmotor symptoms include neuropsychiatric issues such as anxiety, depression, hallucinations, impulse control disorders, and cognitive impairment, as well as autonomic dysfunction, which may present as gastrointestinal, urinary, and sexual disturbances. Nonmotor symptoms also include excessive sweating, orthostatic hypotension, and sleep disturbances. Management of PD requires recognition of both motor and nonmotor symptoms as well as an understanding of the relationship between these symptoms and how they can be affected by treatments for PD. Therapy should be individualized for each patient, as treatments for the motor symptoms of PD can improve some nonmotor symptoms while they can worsen others. In many cases, symptom-specific treatments are necessary to control nonmotor symptoms of PD.

Evaluation and management of orthostatic hypotension

Orthostatic hypotension is defined as a decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within three minutes of standing when compared with blood pressure from the sitting or supine position. It results from an inadequate physiologic response to postural changes in blood pressure. Orthostatic hypotension may be acute or chronic, as well as symptomatic or asymptomatic. Common symptoms include dizziness, lightheadedness, blurred vision, weakness, fatigue, nausea, palpitations, and headache. Less common symptoms include syncope, dyspnea, chest pain, and neck and shoulder pain. Causes include dehydration or blood loss; disorders of the neurologic, cardiovascular, or endocrine systems; and several classes of medications. Evaluation of suspected orthostatic hypotension begins by identifying reversible causes and underlying associated medical conditions. Head-up tilt-table testing can aid in confirming a diagnosis of suspected orthostatic hypotension when standard orthostatic vital signs are nondiagnostic; it also can aid in assessing treatment response in patients with an autonomic disorder. Goals of treatment involve improving hypotension without excessive supine hypertension, relieving orthostatic symptoms, and improving standing time. Treatment includes correcting reversible causes and discontinuing responsible medications, when possible. Nonpharmacologic treatment should be offered to all patients. For patients who do not respond adequately to nonpharmacologic treatment, fludrocortisone, midodrine, and pyridostigmine are pharmacologic therapies proven to be beneficial.

Cerebrovascular diseases at the C. Mondino National Institute of Neurology: from Ottorino Rossi to the present day

This paper traces the development of research and healthcare models in the field of cerebrovascular disorders at the C. Mondino National Institute of Neurology in Pavia, Italy. It starts with a description of the original experiences of Ottorino Rossi and his thesis on atherosclerosis which date back to the beginning of the last century; it then illustrates the connections between his seminal essay and the future directions followed by research in this institute, through to the development of one of the first stroke units in Italy. In this context, we examine a large range of scientific approaches, many related to cerebrovascular diseases (such as headaches) and autonomic disorders, and some of their biological and physiological markers. The originality of an approach also based on tools of advanced technology, including information technology, is emphasised, as is the importance of passion and perseverance in the pursuit of extraordinary results in what is an extremely complex and difficult field.

Isolated sympathetic failure with autoimmune autonomic ganglionopathy

A 16-year-old boy had a gradual onset of post-exercise myalgia with progressive fatigue and dizziness. He had bradycardia (37 beats/minute) with low supine and normal standing norepinephrine levels (56 and 311 pg/mL, respectively). He had absent sympathetically mediated vasoconstrictor responses during Valsalva maneuver testing. Circulating ganglionic acetylcholine receptor antibodies were identified. Response was gradual to treatment with intravenous immunoglobulin combined with aggressive symptomatic interventions (permanent pacemaker implantation and treatment with pyridostigmine, midodrine, and modafinil). After the intravenous immunoglobulin treatment, his autoantibody levels decreased and the autonomic abnormalities resolved. After a reconditioning exercise program and eventually undetectable antibody titers, he achieved complete recovery. The patient continued to do well after his pacemaker was removed and his medications were discontinued. Thus, severe isolated sympathetic nervous system failure can occur in adolescents with autoimmune autonomic ganglionopathy, and multifaceted treatment can be effective.

[Diagnosis and correction of the vegetative dysfunction of the aircrew]

The article is concerned with the topical issue of aeromedicine--diagnosis and correction of the vegetative dysfunction of the aircrew. Causative factors leading to the dysfunction are discussed. Clinical and instrumental methods of the valuation of vegetative status and vegetative supporting of activity are studied. The data of researches is represented; the possibility of the correction of elicited variant of the vegetative dysfunctions with the help of drug and drug-free modalities is evaluated.