Tilt table testing in neurology and clinical neurophysiology

Saal, Dirk P.; Thijs, Roland D.; Dijk, J. Gert van

doi:10.1016/j.clinph.2015.07.037

Cited by 30 publications

(22 citation statements)

References 73 publications

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“…Autonomic challenges usually consist of physical stimuli or actions that elicit changes in sympathetic and parasympathetic activity, often reflected as blood pressure and heart rate alterations. While certain tests are impractical inside an MRI environment (such as orthostatic changes elicited either by a tilt table or by changing posture from sitting to standing: Faraji et al, 2011 ; Saal et al, 2015 ), the majority of procedures involving a static body position with minimal electrical equipment are feasible (Adkisson and Benditt, 2015 ). The Valsalva maneuver can be performed in the supine position, with plastic tubing connected to a pressure sensor outside the scanner room and some form of signal/cue to indicate to the participant when to blow into the tube, and when sufficient pressure is reached.…”

Section: Functional Mri Methodologymentioning

confidence: 99%

Functional Imaging of Autonomic Regulation: Methods and Key Findings

et al. 2016

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Central nervous system processing of autonomic function involves a network of regions throughout the brain which can be visualized and measured with neuroimaging techniques, notably functional magnetic resonance imaging (fMRI). The development of fMRI procedures has both confirmed and extended earlier findings from animal models, and human stroke and lesion studies. Assessments with fMRI can elucidate interactions between different central sites in regulating normal autonomic patterning, and demonstrate how disturbed systems can interact to produce aberrant regulation during autonomic challenges. Understanding autonomic dysfunction in various illnesses reveals mechanisms that potentially lead to interventions in the impairments. The objectives here are to: (1) describe the fMRI neuroimaging methodology for assessment of autonomic neural control, (2) outline the widespread, lateralized distribution of function in autonomic sites in the normal brain which includes structures from the neocortex through the medulla and cerebellum, (3) illustrate the importance of the time course of neural changes when coordinating responses, and how those patterns are impacted in conditions of sleep-disordered breathing, and (4) highlight opportunities for future research studies with emerging methodologies. Methodological considerations specific to autonomic testing include timing of challenges relative to the underlying fMRI signal, spatial resolution sufficient to identify autonomic brainstem nuclei, blood pressure, and blood oxygenation influences on the fMRI signal, and the sustained timing, often measured in minutes of challenge periods and recovery. Key findings include the lateralized nature of autonomic organization, which is reminiscent of asymmetric motor, sensory, and language pathways. Testing brain function during autonomic challenges demonstrate closely-integrated timing of responses in connected brain areas during autonomic challenges, and the involvement with brain regions mediating postural and motoric actions, including respiration, and cardiac output. The study of pathological processes associated with autonomic disruption shows susceptibilities of different brain structures to altered timing of neural function, notably in sleep disordered breathing, such as obstructive sleep apnea and congenital central hypoventilation syndrome. The cerebellum, in particular, serves coordination roles for vestibular stimuli and blood pressure changes, and shows both injury and substantially altered timing of responses to pressor challenges in sleep-disordered breathing conditions. The insights into central autonomic processing provided by neuroimaging have assisted understanding of such regulation, and may lead to new treatment options for conditions with disrupted autonomic function.

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Section: Functional Mri Methodologymentioning

confidence: 99%

Functional Imaging of Autonomic Regulation: Methods and Key Findings

et al. 2016

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“…In the human health literature, there are already various lines of evidence that slowing down of recovery may signal reduced resilience for a range of subsystems ( SI Appendix , Table S2 ). For instance, subjects with a slow rise in blood pressure following exercise have a five times higher risk of ischemic stroke ( 81 ), and persons with a slow rate of recovery of blood pressure upon standing up are more likely to experience syncope (fainting) ( 82 , 83 ). In psychiatry, slowness of mood change (reflected in elevated temporal correlation and variance of emotions) has been found to be indicative of the risk of falling into a clinical depression later ( 44 , 84 ).…”

Section: Resilience Of the Subsystemsmentioning

confidence: 99%

Quantifying resilience of humans and other animals

Scheffer

Bolhuis

Borsboom

et al. 2018

Proc. Natl. Acad. Sci. U.S.A.

273

321

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All life requires the capacity to recover from challenges that are as inevitable as they are unpredictable. Understanding this resilience is essential for managing the health of humans and their livestock. It has long been difficult to quantify resilience directly, forcing practitioners to rely on indirect static indicators of health. However, measurements from wearable electronics and other sources now allow us to analyze the dynamics of physiology and behavior with unsurpassed resolution. The resulting flood of data coincides with the emergence of novel analytical tools for estimating resilience from the pattern of microrecoveries observed in natural time series. Such dynamic indicators of resilience may be used to monitor the risk of systemic failure across systems ranging from organs to entire organisms. These tools invite a fundamental rethinking of our approach to the adaptive management of health and resilience.

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“…TTTs consist of supine rest followed by head-up tilt, without the use of nitroglycerin (NTG). In some protocols this 'no-NTG phase' is followed by an 'NTG phase' [12,13]. NTG is a potent vasodilator that is reported to increase the sensitivity of the test, although with some loss of specificity [14,15].…”

Section: Introductionmentioning

confidence: 99%

A higher proportion of men than of women fainted in the phase without nitroglycerin in tilt-induced vasovagal syncope

et al. 2020

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Purpose Vasovagal syncope (VVS) affects more women than men. We determined whether this sex ratio affects tilt table test (TTT) results. Methods We retrospectively studied TTT outcomes in suspected VVS. TTT consisted of supine rest, a maximum 20 min of head-up tilt without and, if nitroglycerin was needed, a further maximum 20 min after nitroglycerin administration. TTT was terminated if VVS occurred. We used binary logistic regression for the entire TTT and for each phase, with VVS as outcome and age and sex as predictors. Results TTT provoked vasovagal (pre)syncope in 494 out of 766 tests (64%). The proportion of men and women who fainted during the entire TTT did not differ significantly between the sexes (p = 0.13, corrected for age). A lower proportion of women than men had VVS in the phase without nitroglycerin (odds ratio 0.54; 95% confidence interval 0.37-0.79; p = 0.002, corrected for age), whereas a higher proportion of women than men fainted after nitroglycerin (odds ratio 1.58; 95% confidence interval 1.13-2.21; p = 0.008, corrected for age). These sex differences remained significant after correction for a history of orthostatic versus emotional triggers. The effect of sex on TTT outcome was closely associated with differences of blood pressure change upon tilt-up (lower in men in both TTT phases: without nitroglycerin p = 0.003; with nitroglycerin p = 0.05), but not with heart rate changes. Conclusion Men were more susceptible to induction of VVS without nitroglycerin and women after it. The unexpected findings may be due to sex-specific pathophysiological differences.

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Tilt table testing in neurology and clinical neurophysiology

Cited by 30 publications

References 73 publications

Functional Imaging of Autonomic Regulation: Methods and Key Findings

Functional Imaging of Autonomic Regulation: Methods and Key Findings

Quantifying resilience of humans and other animals

A higher proportion of men than of women fainted in the phase without nitroglycerin in tilt-induced vasovagal syncope

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