儿童不明原因晕厥诊断及血流动力学类型的多中心研究

目的探讨不明原因晕厥患儿的诊断及各种血流动力学类型的变化规律。方法2000-05—2006-04,对在北京、湖南、湖北三地就诊或住院的208例不明原因晕厥或接近晕厥患儿[男87例,女121例;年龄3～19(11.66±2.72)岁],进行诊断学研究并对血流动力学类型进行检测,采用SPSS10.0软件进行统计。结果不明原因晕厥的患儿以女性居多,208例患儿中女性121例(58.2%),男性87例(41.8%);不明原因晕厥的患儿年龄近似正态分布,平均年龄11.66岁。208例不明原因晕厥患儿经直立倾斜试验(HUT)诊断,155例为阳性;基础直立倾斜试验(BHUT)的诊断阳性率达50.48%(105/208);舌下含化硝酸甘油激发的直立倾斜试验(SNHUT)的阳性率为74.52%(155/208),舌下含化硝酸甘油激发的直立倾斜试验的敏感度及诊断价值均为74.52%;在诊断为阳性的患儿中,体位性心动过速类型占60例(28.8%),血管抑制型72例(34.6%),心脏抑制型5例(2.4%),混合型18例(8.7%);53例经BHUT及SNHUT诊断为阴性的患儿,其血流动力学类型正常(25.5%)。不同年龄组(年龄<12岁和年龄≥12岁)间患儿性别比较差异无显著性(P>0.05);两组(年龄<12岁和年龄≥12岁)血流动力学类型分布差异有显著性(P<0.05);不同性别患儿血流动力学类型分布差异无显著性(P>0.05)。患儿主诉症状不同(主诉头晕、未晕倒和主诉晕厥发作)血流动力学类型分布差异有显著性(P<0.05);晕厥持续时间不同(持续时间≤5min和持续时间>5min)血流动力学类型分布差异无显著性;血流动力学类型不同,患儿的晕厥诱因、晕厥先兆、晕厥伴随症状及晕厥后状态不同。结论不明原因晕厥好发于女孩,并且高峰年龄接近12岁,直立倾斜试验对于此病的诊断阳性率较高;不同年龄段的患儿血流动力学类型分布不同。对于不明原因晕厥患儿,应采用HUT进行诊断并判断其血流动力学类型,以便于合理用药治疗。     

基础直立倾斜试验对儿童不明原因晕厥的诊断研究

为探讨基础直立倾斜试验对不明原因的晕厥患儿的诊断价值，应用直立倾斜试验（倾斜角度６０度，试验持续时间４５分钟）对４２例不明原因的晕厥患儿进行诊断研究，并以１３名正常小儿作对照。结果：基础直立倾斜试验在不明原因晕厥患儿的阳性率为６７％，对照组阳性率为０。诊断敏感度、特异度及诊断价值分别为６７％、１００％及７４％。阳性反应诱发时间为２２±１２分钟。在２８例阳性反应患儿中，１５例为血管抑制型反应，表现为血压明显下降，心率增快；３例为心脏抑制型反应，表现为心率明显下降，血压不变；１０例为混合型反应，其血压、心率均明显下降。提示：基础直立倾斜试验可较好地、客观地对血管迷走性晕厥进行诊断。     

神经系统及精神疾病

05 1 72 2　直立倾斜试验对儿童血管迷走性晕厥的诊断价值 /王慧远…∥临床儿科杂志 .-2 0 0 4,2 2 (6) .-3 91临床资料 :晕厥组 :不明原因晕厥患儿 45例 ,对照组 :无晕厥病史正常儿童 2 0例。 2组病例体检、心电图、超声心动图、脑电图、脑 CT及血糖均正常。晕厥组和对照组小儿间性别、年龄、基础血压及基础心率差异均无显著性(P>0 .0 5 ) ,晕厥次数在直立倾斜试验阳性及阴性反应小儿中 ,差异也无显著性。结果 :直立倾斜试验阳性率晕厥组阳性率 64.4% (2 9/45例 ) ,对照组阳性率 5 .0 % (1 /2 0例 ) ,2组阳性率差异非常显著 (P<0 .0 0 1 …     

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目的探讨舌下含服硝酸甘油倾斜试验(SNHUT)对儿童血管迷走性晕厥(VVS)的诊断价值。方法2001年3月至2005年5月在中南大学湘雅二医院儿童晕厥专科就诊或住院的不明原因晕厥(UPS)患儿143例,年龄4～18(12.10±3.03)岁,男58例,女85例。电动倾斜床直立倾斜70°行基础直立倾斜试验(BHUT),并对其阴性者中的64例在同一角度直接给予舌下含服硝酸甘油片0.2mg,再次评价试验结果。用SPSS11.0软件进行微机统计学处理。结果(1)BHUT阳性率29.4%(42/143),其中女性占73.8%(31/42);SNHUT64例,阳性44例,阳性率为68.7%。SNHUT显著地提高了VVS的检出率。(2)出现阳性结果的时间BHUT为(21.31±13.24)min,SNHUT为(5.41±4.23)min。(3)反应类型BHUT及SNHUT阳性患儿共86例,血管抑制型83.7%(72/86),女性占53.5%(46/86);心脏抑制型7.0%(6/86),均为女性;混合型9.3%(8/86),女性占62.5%(5/8)。(4)副反应舌下含服硝酸甘油64例,未见明显不耐受现象或其他副反应。结论SNHUT能提高儿童VVS诊断阳性率,副反应小,使用方便,可在儿科临床推广。     

直立倾斜试验在儿童血管迷走性晕厥中的诊断价值

目的：探讨直立倾斜试验儿童血管迷走性晕厥的诊断价值。方法：对24例不明原因晕厥的患儿进行基础直立倾斜试验，并以12名正常儿童作对照，在倾斜过程中动态观察心电图、血压、心率，并进行分析。结果：24例晕厥患儿中，基础直立倾斜试验阳性16例，而对照组为0.诊断敏感度为67%,特异度为100%,诊断价值为78%.16例阳性反应中，心脏抑制型反应3例（19%），表现为心动过缓，血压无变化；血管抑制型反应9例（56%），表现为血压下降，心率加快；混合型反应4例（25%），表现为心率、血压均有明显下降。结论：基础直立倾斜试验可作为儿童血管迷走性晕厥的一种重要诊断方法。     

血管迷走性晕厥的诊断与防治

晕厥是引起一过性意识丧失最常见的原因,引起晕厥的病因主要有器质性晕厥、神经介导的反射性疾病、代谢性疾病和精神性疾病,其中自主神经介导性晕厥最常见.自主神经介导性晕厥主要包括血管迷走性晕厥(VVS)、体位性心动过速综合征(POTS)及直立性低血压(OH)等.直立倾斜试验(HUT)是VVS诊断中的重要客观检查手段,它包括基础直立倾斜试验(BHUT)和舌下含化硝酸甘油激发的倾斜试验(SNHUT).VVS的治疗主要包括直立训练等物理疗法、增加患儿盐和液体的摄入量及药物治疗等.     

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目的探讨直立倾斜试验(HUTT)对儿童血管迷走性晕厥(VVS)反复发作的预测价值。方法2001-01—2006-08在中南大学湘雅二医院晕厥专科门诊就诊或住院的不明原因晕厥患儿251例,男112例,女139例,年龄418(12.25±3.27)岁。依临床晕厥发生频次分A组(晕厥发作仅1次,n=54)、B组(晕厥发作24次,n=137)与C组(晕厥发作≥5次,n=60)。HUTT在取得知情同意后采用基础直立倾斜试验(BHUT,n=251)及舌下含服硝酸甘油倾斜试验(SNHUT,n=92)。结果(1)HUTT阳性率与晕厥频次关系:BHUT阳性率随晕厥频次增加而递增(χ2=4.285,P>0.05),SNHUT阳性率与晕厥频次不呈线性关系(χ2=1.316,P>0.05),HUTT总阳性率(指BHUT阳性率+SNHUT阳性率)亦随晕厥频次增加而递增(χ2=3.809,P>0.05)。(2)HUTT反应类型与晕厥频次关系:无论是BHUT还是SNHUT,反应类型以血管抑制型为主,BHUT或SNHUT在不同晕厥频次组间比较无明显差异(分别为χ2=3.008,P>0.05;χ2=2.426,P>0.05)。结论HUTT与儿童VVS临床晕厥反复发作频次无明显关系,对儿童VVS临床反复晕厥发作没有预测价值。     

儿童不明原因晕厥的临床特征与直立倾斜试验关系的研究

目的　分析直立倾斜试验阳性与不明原因晕厥患儿临床特征的关系。方法　对 47例不明原因晕厥患儿 ,根据其直立倾斜试验的结果分为二组 :直立倾斜试验阳性组和阴性组 ,将其临床特征进行对比分析研究 ,并对其各个临床特征与直立倾斜试验的结果进行Logistic回归分析。 结果　不明原因晕厥患儿的性别、年龄、有无晕厥诱因及有无晕厥先兆对直立倾斜试验的结果有影响 ,根据Logistic回归分析 ,对直立倾斜试验结果有显著影响的因素依次为晕厥诱因、晕厥先兆和年龄。结论　对于发生于青春期女孩不明原因的晕厥 ,而患儿又有较明确的晕厥诱因和晕厥先兆者 ,其直立倾斜试验阳性的可能性较大 ,临床可诊断为血管迷走性晕厥。     

直立倾斜试验受试儿童心理恐惧的评估

目的 探讨直立倾斜试验（HUTT）的不同倾斜角度及不同试验反应对受试儿童心理恐惧的影响。方法 不明原因晕厥或先兆晕厥儿童107 例,年龄5.5~17.8（12.0±2.8）岁,男52 例,女55 例,随机选取60°、70°或80°进行基础直立倾斜试验（BHUT）,BHUT 阴性者保持同一倾斜角度进行舌下含化硝酸甘油倾斜试验（SNHUT）。采用Wong-Baker 面部表情疼痛量表,在试验结束时让受试儿童对HUTT 过程中心理恐惧程度进行自我评定。结果 倾斜角度为60°、70°、80°的3 组受试儿童HUTT 阳性率、血流动力学改变、反应类型分布差异均未见统计学意义（P>0.05）。60°、70°、80° 3 种倾斜角度对受试儿童心理恐惧程度的影响呈递增趋势,但差异无统计学意义（P>0.05）。HUTT 阳性儿童（n=76）心理恐惧程度明显高于HUTT 阴性儿童（n=31）（P<0.01）。结论 HUTT 可引起受试儿童心理恐惧;60°、70°、80° 3 种倾斜角度受试儿童心理恐惧呈递增趋势,但差异不显著;HUTT 阳性反应可显著增加受试儿童心理恐惧。     

直立倾斜试验对不明原因晕厥患儿的诊断价值

目的：讨基础直立倾斜试验对不明原因晕厥(UPS)患儿的诊断价值。方法：UPS患儿30例,年龄6～18岁,平均(11.74±2.82)岁,采用电动倾斜床取头高脚低位直立倾斜70° 后每 5 min自动测量血压和心电变化,评价倾斜试验结果。结果：30例UPS中倾斜试验阳性10例(占 33.3%),反应类型为心脏抑制型及血管抑制型各5例,晕厥发作在倾斜站立10～40 min,平均(24.0±12.2) min。结论：倾斜试验是诊断儿童血管迷走性晕厥(VVS)的有效方法,对临床UPS患儿具有很好地诊断价值。     

Sublingual Isosorbide Dinitrate-Stimulated Tilt Test for Diagnosis of Vasovagal Syncope in Children and Adolescents

Vasovagal syncope is the most likely cause of syncope in the young. Head-up tilt-table test (HUT) provides the ability to provoke vasovagal syncope under controlled laboratory settings. In adult populations, pharmacologic stimulation with intravenous/sublingual isosorbide dinitrate (ISDN) has been shown to be an alternative to isoproterenol for increasing the diagnostic yield of HUT. In this study, 40 patients aged 9-18 years with unexplained syncope and 12 healthy age-matched children were evaluated by HUT to 70 degrees for 45 minutes. If tilting alone did not induce symptoms (syncope and presyncope), 0.1 mg/kg ISDN was given while the patient lay supine. After 5 min, the table was tilted to 70 degrees for 15 min or until the symptoms occurred. The control group consisted of 12 healthy age-matched children studied in a similar manner. Six patients (15%) had a positive basal tilt test. Twenty-five patients (62.5%) lost consciousness following ISDN administration. In the control group, nobody had a syncopal episode during the basal tilt test. However, ISDN administration resulted in 1 positive response (8.3%). The sensitivity of the test was 77.5% and its specificity was 91.6%. It is concluded that sublingual nitroglycerin HUT is suitable for routine clinical practice in children and adolescents with unexplained syncope.     

The value of the head-up tilt table test for with unexplained syncope in children and young adolescents

Syncope occurs in about 15% of children and young adolescents. The diagnosis of syncope of unknown origin is frequently difficult. In 1986, Kenny et al. introduced the Head-up Tilt Table Test (HUT), which enables to reproduce syncope. The aim of the study was to evaluate HUT in diagnosis of syncope in children and young adolescents. Ninety five children and young adolescents (57 females, 38 males, age range 7-18 years) with recurrent syncope of unexplained etiology were referred for HUT. The study group was divided into two subgroups: A--with history consistent with vasovagal syncope (VVS) and B--with non-characteristic symptoms for VVS. HUT was performed according to the Westminster protocol. The patient was tilted at 60 degree for 45 min. or until syncope occurred. Positive response to HUT was 36%. Negative outcome occurred in 59%. Non-diagnostic HUT was observed in 5%. The vasodepressive type of VVS was recognised in 35%, cardioinhibitory in 12% and mixed in 53%. In group A positive response of HUT occurred in 65% of pts., negative in 31%. In group B positive HUT was observed in 4% of pts. and negative in 89%. CONCLUSIONS: 1. In children and young adolescents head-up tilt test is a very useful diagnostic method. 2. In patients referred for the head-up tilt test the history of syncope should be taken into consideration.     

Association of Clinical Characteristics of Unexplained Syncope with the Outcome of Head-Up Tilt Tests in Children

The aim of this study was to clarify the association of clinical characteristics of unexplained syncope with the outcome of the head-up tilt test (HUT) in children. A total of 47 patients with unexplained syncope were classified into two groups according to their outcomes of HUT: the positive response group and the negative response group. We reviewed their clinical data as well as the results of HUT and analyzed them with logistic regression method. The results showed that the incidence of positive responses to HUT was higher in girls than in boys (8/22 vs 10/7, p < 0.05). Compared with fainted children younger than 12 years of age, 12- to 16-year-old adolescents with unexplained syncope had a high positive outcome of HUT (30 vs 72.9%, p < 0.05). Compared with fainted children with negative response of HUT, children with positive response to HUT often had syncope in special circumstances (e.g., prolonged standing, anxiety and fright, and morning exercise), and they often had prodrome, such as pallor, lightheadedness, and nausea (28/30 vs 8/17, p < 0.05). However, the number and duration of syncopal spells did not relate to the positive responses to HUT. The logistic regression analysis showed that three factors significantly influenced the outcome of HUT: predisposing factors of syncope, prodrome of syncope, and age (p < 0.05; OR = 32.9434, 17.7281, and 2.7842, respectively). Hence, if pubertal girls with unexplained syncope had clear predisposing factors and prodromes, they were likely to have positive responses to HUT, and they were likely to be clinically considered as having vasovagal syncope.     

血管迷走性晕厥患儿40例

目的探讨不同类型血管迷走性晕厥(VVS)患儿的临床特征及实验室检查指标间的差异。方法经常规病史询问、体格检查、卧立位血压、辅助检查、直立倾斜试验(HUT)确诊的VVS患儿40例,比较不同类型患儿的临床特征及实验室指标间的差异。结果VVS患儿的血流动力学类型以血管抑制性为主。不同类型VVS患儿的临床特征,包括晕厥的诱因、先兆、发作频率、持续时间、基础心率、血压及血清电解质水平等均无显著差异。结论血管抑制型反应是血管迷走性晕厥患儿的主要血流动力学类型。     

Head-up tilt for the evaluation of syncope of unknown origin in children

Fifteen patients aged 10 to 18 years with syncope of unknown origin, and 10 healthy control children aged 11 to 18 years, were evaluated by head-up tilt to 60 degrees for 60 minutes. Six patients (43%) reproduced symptoms of syncope during the examination. Four had a typical vasovagal reaction; two had marked hyperventilation. None of the children in the control group had syncope. The head-up tilt test offers a simple, noninvasive, high-yielding diagnostic tool for evaluation of syncope in children.     

一氧化氮和内皮型一氧化氮合成酶与血管迷走性晕厥发病的关系

目的：探讨一氧化氮和内皮型一氧化氮合成酶与儿童血管迷走性晕厥发病的关系。方法：血管迷走性晕厥患儿14例（A组）,其他原因引起晕厥患儿10例（B组）,健康志愿者20例（C组）。于倾斜试验（HUT）前和倾斜不同时间测定A组与B组患儿的血浆一氧化氮（NO）水平,同时对3组儿童进行内皮型一氧化氮合成酶（eNOS）基因G894T多态性检测。结果：①A组患儿出现阳性反应时血浆NO水平较平卧时显著升高（76.7±9.6 vs 90.0±11.4 μmol/L, P<0.05）;②A组患儿在症状好转后血浆NO水平较试验前显著降低（82.7±9.2 vs 61.5±6.9 μmol/L,P<0.01）;③B组患儿倾斜时血浆NO水平较平卧时差异无显著性;④A,B两组患儿的血压、心率变化与NO水平无显著相关性;⑤A组患儿eNOS基因G894T突变型基因频率显著高于B组与C组(42.9% vs 10%, P<0.05)。结论： 倾斜体位时血浆NO水平异常升高可能参与了血浆血管迷走性晕厥的发病机制,而其升高水平可能与eNOS基因G894T多态性表达有关。     

The diagnostic protocol in children and adolescents with syncope: a multi-centre prospective study

Aim: The appropriate diagnostic protocol for children with syncope has not been well established. A diagnostic protocol was developed and prospectively implemented to improve the diagnostic performance of paediatricians.
Methods: The study population included 474 consecutive patients (range 6–17 years) presenting with a syncopal spell in one of the five participating hospitals of China. In step 1, all patients underwent initial evaluation for history, physical examination, standing test and standard electrocardiography (ECG). In step 2, priority was given to cardiographic tests for possibly cardiogenic syncope, or electroencephalographic examination and brain imaging for suspected neurological syncope, or psychiatric tests for suspected psychiatric syncope. Patients with unexplained syncope underwent head-up tilt testing (HUT).
Results: The initial evaluation gave a definite diagnosis in 59 (12.4%) and possible diagnosis in 54 of the 474 patients. Further testing gave a definite diagnosis for 326 patients (69.7%). After the entire diagnostic protocol, definite diagnosis was established in 385 patients (81.1%). Autonomic-mediated reflex syncope (AMS) accounted for 73.0% of cases. The average cost of diagnostic results per patient was RMB 1030.24 ± 150.09 ($118.42 ± 17.25).
Conclusion: The use of a simplified diagnostic protocol for children and adolescents with syncope improves diagnostic yield.     

Head-up tilt test: A highly sensitive,specific test for children with unexplained syncope

Unexplained syncope may cause diagnostic and therapeutic problems in children. The head-up tilt test has been shown to be a useful tool for investigating unexplained syncope, especially for diagnosis of neurally mediated syncope. In this study 20 patients aged 9–18 years (12.0±2.5 years) with syncope of unknown origin and 10 healthy age-matched children were evaluated by head-up tilt to 60° for 25 minutes. The test was considered positive if syncope or presyncope developed in association with hypotension, bradycardia, or both. If tilting alone did not induce symptoms (syncope or presyncope), isoproterenol infusion was administered with increasing doses (0.02–0.08 μg/kg per minute). During the tilt test, symptoms were elicited in 15 (75%) of the patients with unexplained syncope but in only one (10%) of the control group (p<0.001). The sensitivity of the test was 75% and its specificity 90%. Three patterns of response to upright tilt were observed in symptomatic patients: vasodepressor pattern with an abrupt fall in blood pressure in 67%; cardioinhibitory pattern with profound bradycardia in 6%; and mixed pattern in 27%. In patients with positive head-up tilt, there were sudden decreases in systolic blood pressure (from 130±15 to 61±33 mmHg) and in mean heart rate (from 147±26 to 90±38 beats per minute) (p<0.001) during symptoms. Treatments with atenolol 25 mg/day has shown complete suppression of syncope in positive responders during a mean follow-up period of 18±6 months. The head-up tilt test is a noninvasive, sensitive, specific diagnostic tool for evaluating children with unexplained syncope.