De Musset sign

Specialty: Cardiovascular.

• rhythmic oscillation of the head
• pulse-synchronous pitch

Why it occurs

• Chronic severe aortic valve insufficiency
• Large ascending aortic aneurysm with flow transmission
• Severe combined aortic stenosis and aortic insufficiency
• Extracranial giant arteriovenous fistula
• Massive tricuspid regurgitation (with transmission of venous wave V to the neck and head)

Initial workup

Transthoracic Doppler echocardiogram to quantify the degree of regurgitation of the aortic or tricuspid valve, assess the end-systolic and end-diastolic diameter of the left ventricle, evaluate the ejection function and rule out valve vegetations due to endocarditis; Multidetector computed tomography (Angio-CT) of the entire aorta (thorax and abdomen) to accurately size the aortic arch and ascending aorta in the event of suspicion of significant aneurysmal dilation; 12-lead electrocardiogram.

Standard management

• Lisinopril — ACEI to reduce left ventricular afterload and attenuate ejective force and regurgitant volume; 5 to 20 mg once daily orally
• Amlodipine — calcium antagonist for the adjuvant control of hypertension and reduction of systolic pressure; 5 to 10 mg per day orally
• Furosemide — loop diuretic if there are associated signs of congestive heart failure; 20 to 40 mg once daily orally
• Warfarin (mandatory anticoagulant indicated if posterior mechanical aortic valve replacement is required; dose adjusted according to the target INR of 2.0 to 3.0).