Workshop/Conference

  2017 Workshop/Conference Title: 59F with nocturnal episodes of altered sensorium Active participants:  Rakesh Biswas  ,  Avinash Kumar  , ...

Saturday, 6 March 2021

Syncopal attacks post Hemiglossectomy

 

60yr lady. Wife of a doctor friend of mine H/o CA tongue. Hemiglosectomy followed by RT done about a year back. Also has Hypothyroid and OSA.
H/o recurrent syncopal attacks for last 1 month. ABG, EEG, ECG, Hotler, HUTT, Hemogram, TSH, Electrolytes all normal. MRI brain normal.
MRA shows about 60% block of Carotids on left side.
What to do next?
No photo description available.
Sumit Giri
22 comments
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  • Debapriya Mondal
    This could be due to Radiation induced Carotid Artery stenosis or accelerated atherosclerosis (more common in patients with pre-existing risks) or less commonly thrombotic sequelae of cancer itself. It is more likely to be the first. To confirm Carotid intima-media thickness can be measured.
    Invasive treatment is generally reserved for severe cases (>70%) but since this patient is symptomatic invasive options must be considered (Angioplasty & stenting or endarterectomy). We have had a few cases of Carotid Artery stenosis in post radiotherapy patients but none needed invasive treatment. The bad news is, it generally gets worse (chances of stenosis and severity) with survivorship for as long as ten years from radiotherapy. There is some role of statins and antiplatelets in post-intervention patients to prevent future occurrences but without intervention medical treatment has limited role.
    Also, it is of paramount importance to rule out cancer recurrence in her case before considering any invasive treatment, preferably with a PET CT scan.
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    • 2 y
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    • Ambarish Bhattacharya
      Fully agree with you.
      It could be a direct result of radiation or as a result of radical neck dissection.
      My only concern is should I be thinking of anything else?
      Am I missing something in the DD?
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      • 2 y
    • Debapriya Mondal
      I have the burden of tunnel vision here, we see this commonly in post Neck radiation and dissection patients of head neck cancers. There might be many DDx of this lady's symptoms when the cancer is not being considered, but with the cancer Carotid stenosis or accelerated atherosclerosis seems the likeliest of possibilities. I do not have any training in interpreting a carotid intima-media thickness sir, it is best considered by someone with actual experience.
      Is she a patient with elevated atherosclerosis risk though? The problem at the carotid could be one of many. And all the neck manipulation may have just helped what was to happen a few years later.
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      • 2 y
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    • Suman Das
      She got IMRT &it's probably 3-4months only post RDT. Is not it too early to develop post RDT STENOSIS
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      • 2 y
    • Debapriya Mondal
      Yes 3-4 months is early, I'm sorry it appeared from the description that it's been a year. IMRT reduces the chances but it's not a guarantee since there's no definite threshold for carotid stenosis or atherosclerosis ( some degree of stenosis occurs with carotid dose >40Gy, which is hard to adhere) to happen and carotid sparing may not have been possible sir. But if it's 3-4 months only, then it's definitely too early and other possibilities must be considered. I feel an opinion of the treating radiation oncologist will do good since he or she can review the plan (and imaging of that time) and correlate clinically to rule it out.
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      • 2 y
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  • Radiation-Induced Carotid Artery Stenosis: A Comprehensive Review of the Literature
    NCBI.NLM.NIH.GOV
    Radiation-Induced Carotid Artery Stenosis: A Comprehensive Review of the Literature
    Radiation-Induced Carotid Artery Stenosis: A Comprehensive Review of the Literature
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    • 2 y
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    • 2 y
  • Ambarish Bhattacharya
    Any other DD that I should be thinking of?
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    • 2 y
  • Rakesh Biswas
    Admin
    All other causes of syncope needs to be considered beginning with cardiac?
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    • 2 y
  • Suman Das
    Has she been seen by ENT surgeons?
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    • 2 y
  • Amit Taneja
    Sorry to butt in but carotid artery disease and particularly unilateral disease is highly unlikely to be causing syncope. TIA yes, syncope no
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    • 2 y
  • Ambarish Bhattacharya
    And ultimately
    No photo description available.
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    • 2 y
  • Rakesh Biswas
    Admin
    Ambarish
     what is the interpretation?
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    • 2 y
  • Rakesh Biswas
    Admin
    A caveat: "Due to a lack of a gold standard, sensitivity and specificity of the tilt table test for patients with vasovagal syncope is not exactly known."
    Second, the reproducibility of a positive head-up tilt table test varies enormously
    "Third, several studies have shown that the mechanism of syncope during a tilt table test is not equivalent to that of a spontaneous syncope."
    Personally I tend to look at vaso vagal as a diagnosis of exclusion.
    Management and therapy of vasovagal syncope: A review
    NCBI.NLM.NIH.GOV
    Management and therapy of vasovagal syncope: A review
    Management and therapy of vasovagal syncope: A review
    2
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    • 2 y
at

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