Conference title: Patient centred clinical problem solving 2018
Workshop Title: Syncope in presence of comorbidities
Guest faculty: Dr Ambarish Bhattacharya sharing his patient
Active participants:
Ambarish Bhattacharya -
Consultant at Nightingale Hospital,Kolkata, Consultant (medicine) at Spandan Hospital and Consultant at The Apollo Clinic, Saltlake
Debapriya Mondal -
Senior resident in Medical oncology at Tata Medical Center
Suman Das -
Consultant Maxillofacial Surgeon at Bellevue Clinic, Consultant Oral & Maxillofacial surgeon at Ramakrishna Mission Seva Pratisthan Hospital and Consultant at St Joseph's Hospital
Manas Ghosh - Consultant Medicine at
Sromojibi Hospital, Murshidabad Medical College and Hospital and Monmohini Hospital Beharampur
Rakesh Biswas , Prof Medicine, KIMs, Narketpally
Passive participants: 1800 asynchronous online global participants
consisting of MBBS and MD students, question senior residents, independent researchers and faculty Professors in global locations but maximum represented from Indian subcontinent as well as Europe, US, Australia
Conversational learning outcomes:
Dr Ambarish Bhattacharya presents the patient data:
"60yr lady. 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?
Active participants inputs:
Debapriya Mondal -
Senior resident in Medical oncology at Tata Medical Center
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.
Response to input 1 from Dr 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?
Input 2 from 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.
Input 1 from Consultant Maxillofacial Surgeon at Bellevue Clinic, Consultant Oral & Maxillofacial surgeon at Ramakrishna Mission Seva Pratisthan Hospital and Consultant at St Joseph's Hospital
She got IMRT &it's probably 3-4months only post RDT. Is not it too early to develop post RDT STENOSIS
Response from 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.
Input from Dr Amit Taneja, Faculty Medical College, Wisconsin
Sorry to butt in but carotid artery disease and particularly unilateral disease is highly unlikely to be causing syncope. TIA yes, syncope no
Ambarish Bhattacharya inputs around further data from patient:
The tilt test is suggestive of vaso vagal.
Input 1 from Rakesh Biswas
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.
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