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the more serious causes of exercise-induced syncope and to treat the patient appropriately Carotid Sinus Syncope The carotid sinus is normally sensitive to stretch and gives rise to sensory impulses carried via the nerve of Hering, a branch of the glossopharyngeal nerve, to the medulla Massage of one of the carotid sinuses or of both alternately, particularly in elderly persons, causes (1) a re ex cardiac slowing (sinus bradycardia, sinus arrest, or even atrioventricular block) the vagal type of response, or (2) a fall of arterial pressure without cardiac slowing the vasodepressor type of response Another ( central ) type of carotid sinus syncope was in the past ascribed to cerebral arteriolar constriction, but such an entity has never been validated Faintness or syncope due to carotid sinus sensitivity has reportedly been initiated by turning of the head to one side while wearing a tight collar or even by shaving over the region of the sinus However, the absence of a history of such an association does not exclude the diagnosis The attack nearly always occurs when the patient is upright, usually standing The onset is sudden, often with falling Small convulsive movements occur quite frequently in both the vagal and vasodepressor types of carotid sinus syncope The period of unconsciousness in carotid sinus syncope seldom lasts longer than 30 s, and the sensorium is immediately clear when consciousness is regained The majority of the reported cases have involved men In a patient displaying faintness on massage of one carotid sinus, it is important to distinguish between the benign disorder (hypersensitivity of the carotid sinus) and a more serious condition atheromatous narrowing of the basilar or opposite carotid artery (see Chap 34) In the latter circumstance, it is important to avoid compression of the carotid artery, particularly if a carotid bruit is heard over either carotid vessel A number of other types of purely re exive cardiac slowing can be traced to direct irritation of the vagus nerves (from esophageal diverticula, mediastinal tumors, gallbladder stones, carotid sinus disease, bronchoscopy, and needling of body cavities) Here, the re ex bradycardia is more often of sinoatrial than atrioventricular type Weiss and Ferris called such faints vagovagal Through a similar mechanism, tumors or lymph node enlargements at the base of the skull or in the neck that impinge on the carotid artery, as well as postradiation brosis, are capable of causing dramatic syncopal attacks, sometimes preceded by unilateral head or neck pain Often the episodes are unpredictable, but some patients nd that turning the head stimulates an attack The mechanism in one of our patients was primarily a vasodepressor response; patients with prominent bradycardia have generally had tumors that directly surrounded or in ltrated the glossopharyngeal and vagus nerves (Frank et al; see also MacDonald et al) If the tumor can be safely removed from the carotid region, the syncope often abates; in many cases, however, intracranial section of the ninth and upper rootlets of the tenth nerves on the side of the mass is necessary Syncope in Association with Glossopharyngeal Neuralgia Glossopharyngeal neuralgia (also referred to as vagoglossopharyngeal neuralgia) (see discussion in Chap 47, Diseases of Cranial Nerves, page 1185) typically begins in the sixth decade with paroxysms of pain localized to the base of the tongue, pharynx or larynx, tonsillar area, or an ear In only a small proportion of cases (estimated at 2 percent) are the paroxysms of pain complicated by.

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In neurology more than any other specialty, the physician is dependent upon the cooperation of the patient for a reliable history, especially for a description of symptoms that are unaccompanied by observable signs of disease And if the symptoms are in the sensory sphere, only the patient can tell what he* sees, hears, or feels The rst step in the clinical encounter is to enlist the patient s trust and cooperation and make him realize the importance of the examination procedure The practice of making notes at the bedside or in the of ce is particularly recommended Immediate recording of the history assures maximal reliability Of course, no matter how reliable the history appears to be, veri cation of the patient s account by a knowledgeable and objective informant is always desirable The following points about taking the neurologic history deserve further comment: 1 Special care must be taken to avoid suggesting to the patient the symptoms that one seeks In the clinical interview, the

*Throughout this text we follow the traditional English practice of using the pronoun he, his, or him in the generic sense whenever it is not intended to designate the gender of a speci c individual

Degenerative diseases Amyotrophic lateral sclerosis Huntington disease Parkinson disease Alzheimer disease Macular degeneration Autoimmune neurologic diseases Multiple sclerosis Stroke, all types CNS trauma Head Spinal cord Metabolic Diabetic retinopathy Headache Epilepsy Back pain Peripheral neuropathy Total Inherited Diabetic neuropathy Mental retardation Severe Moderate Schizophrenia Manic depressive illness

Since we created a ratio spread and covered the outside with a call option, we now have limited risk, but also limited pro t potential The top side breakeven for the market is calculated by subtracting the captured premium from the outside purchased call options: 120 strike price 193 premium 11807 underlying breakeven

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