[Posterior inferior cerebellar artery infarction with episodic postural diplopia as the initial symptom: A case report].

Accurate and timely diagnosis of posterior circulation ischemic stroke is a challenge for emergency neurology clinicians, even MRI scan which is believed to be sensitive to acute ischemic lesions may be negative. It is particularly important to obtain the typical or characteristic symptoms and signs of the patients through comprehensive physical examination. We report a case of posterior inferior cerebellar artery (PICA) territory infarction with "episodic postural diplopia" as the initial symptom, hoping that clinicians notice the vertical diplopia caused by the disfunction of otolith gravity conduction pathway, which is characterized by the degree of diplopia being affected by postural changes. A 44-year-old man was in hospital due to episodic postural diplopia for 4 months, dizziness and unstable walking for 5 days. In the past four months, the patient had endured episodic diplopia attack for 8 times when standing or walking, which could be relieved obviously while lying down and gradually disappeared within 5-10 minutes. He had not seen a doctor since the outbreak of the novel coronavirus. Five days before admission, diplopia worsened accompanying obvious vertigo, nausea and vomiting, left facial numbness, and hiccups. The diplopia could be relieved after taking the supine position, but not completely disappear as before. Physical examination showed a triad of ocular tilt response (OTR), namely static ocular rotation (SOT), skew deviation (SD) and head tilt (HT). And also subjective visual vertical (SVV) deviation was found. Those signs were considered for otolith gravity conduction system involvement. Combined with other clinical signs, such as Horner signs, crossed sensory disorders, ataxia, and MRI scan, it was easy to find the infarction was in the territory of the left PICA. The reasons for the patient's "episodic posi-tional diplopia" in the early stage of the disease were considered as follows: (1) the gravity was less affected in the supine position, the stimulation of the otolith gravity conduction pathway was reduced, so the degree of eye deviation was reduced in the supine position. (2) As an ischemic cerebrovascular disease, the patient experienced a process of transient ischemic attack (TIA) in the posterior circulation, the cerebral blood supply and the hypoperfusion of stenosis were increased after lying down, so the diplopia symptom disappeared. The upright-supine test was recommended for the patients with vertical diplopia. It was recommened to differentiate between otolith pathway involvement and diplopia caused by trochlear nerve palsy.

Attenuated vagally-mediated heart rate variability at rest and in response to postural maneuvers in patients with generalized anxiety disorder.

BACKGROUND: Altered heart rate variability (HRV), an index of autonomic nervous system function, has been reported in generalized anxiety disorder (GAD), but the results have been mixed. Thus, the present study, using a large sample size and better methodology, aims to examine whether GAD is associated with impaired HRV, both at rest and in response to posture challenges. METHODS: In total, 1832 participants were recruited in this study, consisting of 682 patients with GAD (including 326 drug- and comorbidity-free GAD patients) and 1150 healthy controls. Short-term HRV was measured during the supine-standing-supine test (5-min per position). Propensity score matching (PSM), a relatively novel method, was used to control for potential confounders. RESULTS: After PSM algorithm, drug- and comorbidity-free GAD patients had reductions in resting (baseline) high-frequency power (HF), an index for parasympathetic modulation, and increases in the low-frequency/HF ratio (LF/HF), an index for sympathovagal balance as compared to matched controls. Furthermore, the responses of HF and LF/HF to posture changes were all attenuated when compared with matched controls. Effect sizes, given by Cohen's d, for resting HF and HF reactivity were 0.42 and 0.36-0.42, respectively. CONCLUSIONS: GAD is associated with altered sympathovagal balance, characterized by attenuation in both resting vagal modulation and vagal reactivity, with an almost medium effect size (Cohen's d ≈ 0.4), regardless of medication use or comorbidity status.

Comparison between intraocular pressure spikes with water loading and postural change.

BACKGROUND: To compare the agreement between peak intraocular pressures measured through the water drinking test and the supine test, in patients with primary open angle glaucoma. DESIGN: Consecutive, prospective, blinded. PARTICIPANTS: Twenty-one patients from the Glaucoma Unit, Prince of Wales Hospital, Sydney, Australia. METHODS: For the supine test, intraocular pressure was recorded immediately after the patient had lain down and at 20 and 40 min. At the second evaluation, intraocular pressure was measured in each patient after drinking 10 mL/kg body weight of water for the water drinking test. Again, all patients had their intraocular pressure measured at 20 and 40 min (t = 20 and t = 40, respectively). Patients were excluded from the study if they had pre-existing cardiac, renal or pulmonary complications or had concurrent ocular disease or an anatomical abnormality (including angle recession, peripheral anterior synechiae and developmental anomalies of the angle) that may have influenced intraocular pressure. MAIN OUTCOME MEASURE: Bland-Altman analysis. RESULTS: Bland-Altman analysis indicated an overall excellent agreement in terms of mean difference between methods (1.0, -1.0 and -0.90 mmHg, at 0, 20 and 40 min, respectively). Further, with the exception of t = 40, all measured time points had 95% confidence intervals within 6.5 mmHg of their mean difference on the Bland-Altman plot. CONCLUSIONS: There was close agreement between the intraocular pressure values of the supine test and water drinking test. However, as the water drinking test may be uncomfortable and potentially hazardous, there is potential that the supine test may be a safer and more comfortable alternative.