The clinical, angiographic, and Doppler findings are reported for two young patients with recurrent syncope induced by neck hyperextension during stretching. Transcranial Doppler monitoring of both posterior cerebral arteries was performed during head manoeuvres. There were reproducible rapid decreases in blood flow velocities in both patients to an average of 28% and 41% of baseline values when they performed neck hyperextension. These decreases were regularly associated with the patients' symptoms and were not found during rotation or flexion. On return to a neutral head position there was a transient increase of the blood flow velocities to an average of 131% and 136% of baseline values (reactive hyperaemia). Routine four vessel angiography was normal except for the demonstration of very small posterior communicating arteries in one patient. Dynamic angiography showed evidence of extracranial compression of the craniocervical arteries in both patients. It is concluded that decreased blood flow to the posterior circulation is an important factor in the pathogenesis of adolescent stretch syncope.
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