[Autonomic failure as the cause of vertigo and syncope]

Abstract

Background: Vertigo and syncope often occur during orthostatic conditions. A possible cause is asympathicotonic dysregulation with a fall of blood pressure and no increase in heart rate. After the exclusion of secondary disturbances of autonomic innervation. g. in diabetes mellitus, and pharmacological side effects, e.g. tricyclic antidepressants, primary reasons must be considered. We present 2 cases of primary autonomic failure.

Patients: Patient 1 had Parkinson-syndrome, impaired bladder function and orthostatic dysregulation with a maximal drop of blood pressure to 60/40 mm Hg. Patient 2 showed orthostatic dysregulation with a minimal blood pressure of 70/30 mm Hg without further symptoms, in a tilt table examination catecholamines were measured during orthostatic conditions. Patient 1 had normal, and patient 2 very low resting catecholamine plasma levels. Neither patient reacted with a rise of plasma catecholamines when tilted to an upright position. These findings are diagnostic of multiple system atrophy (MSA) in patient 1 and pure autonomic failure (PAF) in patient 2.

Discussion: In PAP only dysautonomic symptoms are found. It has a favourable prognosis. MSA consists of an autonomic dysregulation in combination with parkinsonism, cerebellary and bulbar symptoms, prognosis quo ad vitam is poor. Diagnosis is often established by a tilt table examination and radiology findings, and is often late. Treatment of both diseases consists of pharmacological, e.g. fludrocortisone, vasopressin analogues and ergotamine tartrate as well as non-pharmacological blood pressure stabilizing measures.