Screening for Mild Vertebral Artery Dissection Using 3-Dimensional T1-weighted Black-blood Magnetic Resonance Imaging: A Retrospective Observational Study of 3,049 Consecutive Walk-in Patients Present

Orthostatic intolerance due to orthostatic hypotension (OH) is a common, debilitating and often unrecognized non-motor symptom of Parkinson’s disease (PD) and several forms of atypical Parkinsonism, such as multiple system atrophy (MSA). OH may present with overt symptoms such as light-headedness, blurred vision or syncope. Symptoms can also be more subtle, including cognitive slowing or fatigue, which challenges a timely recognition. Approximately half of people with PD or MSA with OH have co-existent supine hypertension (SH), particularly when autonomic dysfunction is severe. Early recognition and treatment of SH and OH are essential to preserve quality of life and reduce mortality. The Atherosclerosis Risk in Communities (ARIC) study reported a higher cardiovascular risk in those with SH, regardless of seated hypertension, compared to those with seated hypertension alone. However, pharmacological treatment is challenging when SH and OH co-exist. Severe OH is commonly treated with fludrocortisone, which increases blood pressure (BP) during both day and nighttime, thus aggravating SH. The opposite occurs with pharmacological treatment of SH, which aggravates OH. Non-pharmacological interventions that can be tailored to a person’s body position offer an attractive alternative. One example is full-body head-up tilted sleeping (HUTS), which could potentially ameliorate both SH and OH. Specifically, HUTS is thought to reduce supine BP in persons with autonomic dysfunction, which in turn may reduce nocturnal volume loss through nocturia. This helps to preserve the fluid balance and thereby improves OH. However, there is only limited evidence to support the effectiveness of this intervention. Case reports and small studies studied tilt angles between 5 and 13°, with variable results on orthostatic BP depending on the angle and population studied. Only one study focused on PD, and no study investigated the effect on SH. Problems with tolerability were reported for angles of 12° and higher. We investigated the potential of different HUTS angles to reduce nocturnal BP and improve OH. We also studied the effect on nocturia. Furthermore, participant experiences with different angles of HUTS were explored to evaluate the balance between tolerability and efficacy.