Bottom line, Shofar is high maintenance straining. Don’t overdo or you will wind up with cerebral or vascular issues, among other things.
One blow too many
Ami Schattner MD
Hebrew University and Hadassah Medical School, Jerusalem, Israel
Available online 4 January 2004.
To the Editor:
Blowing the Shofar—a wind instrument made from a horn of a ram and used on the Jewish High Holidays—has many religious advantages. On rare occasions, however, it may be associated with an adverse medical outcome.
A healthy 49-year-old man awoke from sleep with parasthesias and weakness of the left arm. The patient was alert and blood pressure on admission was normal. Examination showed left-sided, upper motor neuron signs with hand weakness and arm hemianesthesia. Funduscopic examination was normal. The chest radiograph, electrocardiogram, carotid duplex, and all blood tests were normal. Brain computed tomography revealed a 12-mm, hyperdense right temporal lesion consistent with a small intracerebral hemorrhage. There was no ventricular blood or hydrocephalus. The patient recalled that before sleeping, he practiced blowing the Shofar for about an hour in preparation for the New Year services. His symptoms improved spontaneously, and he declined further investigations and was discharged and followed with no further ill effects. However, the patient stopped blowing the Shofar. Later, contrast-enhanced magnetic resonance angiography did not reveal aneurysm or vascular malformation.
Cerebral hemorrhage in the brain parenchyma usually arises from leakage of tiny vessels affected by an arteriopathy of chronic hypertension or by amyloid angiopathy—a degenerative disorder affecting the elderly. In younger patients who are not hypertensive, who do not have a brain tumor or coagulopathy, and who do not use sympathomimetic drugs, a small arteriovenous malformation is a likely cause .
Blowing the Shofar, or playing wind instruments, is just one of many activities in which straining occurs, including coughing, defecation, lifting heavy loads, and labor. All involve a transient marked elevation of intra-abdominal and intrathoracic pressures as well as substantial circulatory changes . An effect simulating the Valsalva maneuver is a common denominator of all these activities. With the advent of transcranial Doppler ultrasonography, its sequential effects on blood pressure and cerebral blood flow have been particularly well studied [2 and 3].
Cerebrovascular events in wind instrument players, including syncope, carotid artery dissection, transient ischemic attack due to paradoxical embolism, spinal epidural hematoma, and cerebral venous thrombosis, have been reported, albeit rarely . The Shofar is a particularly high-resistance wind instrument requiring an intense expiratory strain and the generation of especially high pressures in order to produce the desired sounds. Mouth pressures of >150 mm Hg and an extreme increase of intrathoracic pressure up to 300 mm Hg for several seconds have been reported for similar types of strain [2 and 5]. The associated Valsalva maneuver was found to lead to marked increases of cerebral blood flow velocity that may reach 100% above baseline, even at moderate intrathoracic pressures of 40 mm Hg [2 and 3]. This is of particular importance because of the simultaneous decrease in the protective extravascular cerebrospinal fluid pressure and increase in arterial pressure. The resulting major increase in the transmural pressure gradient may place patients with cerebral aneurysms or arteriovenous malformation at high risk of rupture and bleeding following the strain [2 and 6].
It is very likely that the association between our patient's 1 hour of Shofar blowing practice and the subsequent primary intracerebral hemorrhage is not coincidental. Except for the rarity of the association, it is a useful reminder of the importance of common conditions that increase intra-abdominal and intrathoracic pressures in facilitating or enhancing intracerebral hemorrhage, and the advisability of preventing their occurrence whenever possible in patients at risk.