Patient
19 year old female
Brief History/Reason for treatment
Episodes of fainting/passing out with and without standing. Both increased and decreased blood pressure as well as heart rate during episodes. Patient also noted very bad car sickness.
Prior Diagnosis:
Autonomic dysfunction-2014. GI paresis/intestinal dysmotility-2018. EDS-2018
Surgeries:
GJ tube, J tube, pyloric stent removal, central line
Medications:
Zofran, Keppra, Midodrine, Remeron and Dilaudid
Limited Exam Findings:
- Vitals were WNL for age
- Pupils were dilated and responded poorly to light bilaterally
- Left sided convergence insufficiency
- Pursuits and saccades were appropriate bilaterally
- Mild left palatal paresis
- Hands/feet palpably cold to touch
- Left-sided inability to touch finger to nose-multiple hesitations
- Poor gait/marching patterns with decreased arm swing bilaterally
- Multiple failure in motor patterns with dual tasking-worse on left
- Romberg’s revealed very little sway
- When standing upright eyes open patient constantly rocks back and forth
- Left-sided spatial awareness was poor during auditory and visual testing
- UPDRS-Left RAM (2) Left wing beating (1)
Imaging:
Digital Motion Xray of Cervical Spine to evaluate upper cervical instability. (See imaging study video) Findings of the study included atlantoaxial (C1/C2) instability bilaterally with left-sided partial arcuate foramen.
Additional Testing:
Patient was put into right and left lateral bending while evaluating a pulse oximeter place on the right index finger. You will notice a 40 beat per minute increase in heart rate with left lateral bending of the head in relation to torso (tipping head to the left) as well as a decrease in SpO2 levels. Heart rate and SpO2 levels respond to normal levels when in neutral position as well as in right lateral bending. Due to significant instability of C1 on C2 as well as autonomic concomitants, the patient was referred for a neurosurgical consultation.
Discussion: Significant compromise of the left vertebral artery due to congenital abnormality (arcuate foramen) and clinical instability of C1/C2
