صفحه 1:
Dizziness & vertigo
صفحه 2:
Definition
* Dizziness is a term used to describe a range
of sensations, such as feeling faint, woozy,
weak or unsteady.
° Dizziness that creates the false sense that
you or your surroundings are spinning or
moving is called vertigo. ...
Frequent dizzy spells or
constant dizziness can significantly affect
your life.
صفحه 3:
Symptoms
» People experiencing dizziness may describe it as any of a
number of sensations, such as:
* A false sense of motion or spinning (vertigo)
* Lightheadedness or feeling faint
* Unsteadiness or a loss of balance
* A feeling of floating, wooziness or heavy-headedness
‘These feelings may be triggered or worsened by walking,
standing up or moving your head.
» dizziness may accompanied by nausea or be so sudden or
severe that you need to sit or lie down. The episode may last
seconds or days and may recur.
صفحه 4:
Epidemiology
One of the most common principal complaints
A recent population-based telephone survey in Germany
showed nearly 30% of the population had experienced
moderate to severe dizziness.
Though most subjects reported nonspecific forms of
dizziness, nearly a quarter had true vertigo
Dizziness is more common among females and older people
صفحه 5:
When to see a doctor
* Generally, see your doctor if you experience
any recurrent, sudden, severe, or prolonged
and unexplained dizziness or vertigo.
* Get emergency medical care if you experience
new, severe dizziness or vertigo along with any
of the following:
صفحه 6:
Sudden, severe headache
Chest pain
Difficulty breathing
Numbness or paralysis of arms or legs
Fainting
Double vision
Rapid or irregular heartbeat
Confusion or slurred speech
Stumbling or difficulty walking
Ongoing vomiting
Seizures
A sudden change in hearing
Facial numbness or weakness
صفحه 7:
Causes
* Dizziness has many possible causes, including
inner ear disturbance, motion sickness and
medication effects. Sometimes it's caused by
an underlying health condition, such as poor
circulation, infection or injury.
صفحه 8:
Inner ear problems that cause dizziness (vertigo)
The sense of balance depends on the combined input from the
various parts of y sensory system. These include :
Eyes, which help you determine where your body is in space
and how it's moving
Sensory nerves, which send messages to your brain about
body movements and positions
Inner ear, which houses sensors that help detect gravity and
back-and-forth motion
صفحه 9:
Vertigo is the false sense that your
surroundings are spinning or moving. With
inner ear disorders, your brain receives signals
from the inner ear that aren't consistent with
what your eyes and sensory nerves are
receiving.
Vertigo is what results as your brain works to
sort out the confusion.
صفحه 10:
Benign paroxysmal positional vertigo (BPPV)
* This condition causes an intense and brief but
false sense that you're spinning or moving.
These episodes are triggered by a rapid
change in head movement, such as when you
turn over in bed, sit up or experience a blow
to the head. BPPV is the most common cause
of vertigo.
صفحه 11:
Infection
¢ Aviral infection of the vestibular nerve, called
vestibular neuritis, can cause intense, constant
vertigo.
٠ If you also have sudden hearing loss, you may
have labyrinthitis.
صفحه 12:
Meniere's disease
* This disease involves the excessive buildup of
fluid in your inner ear. It's characterized by
sudden episodes of vertigo lasting as long as
several hours. You may also experience
fluctuating hearing loss, ringing in the ear and
the feeling of a plugged ear.
صفحه 13:
Migraine
* People who experience migraines may have
episodes of vertigo or other types of dizziness
even when they're not having a severe
headache. Such vertigo episodes can last
minutes to hours and may be associated with
headache as well as light and noise sensitivity.
صفحه 14:
Circulation problems that cause
dizziness
» You may feel dizzy, faint or off balance if your heart isn't
pumping enough blood to your brain. Causes include:
* Drop in blood pressure. A dramatic drop in your systolic blood
pressure — the higher number in your blood pressure reading
— may result in brief lightheadedness or a feeling of
faintness. It can occur after sitting up or standing too quickly.
This condition is also called orthostatic hypotension.
٠ Poor blood circulation. Conditions such as cardiomyopathy,
heart attack, heart arrhythmia and transient ischemic attack
could cause dizziness. And a decrease in blood volume may
cause inadequate blood flow to your brain or inner ear.
صفحه 15:
Other causes of dizziness
* Neurological conditions. Some neurological disorders — such
as Parkinson's disease and multiple sclerosis — can lead to
progressive loss of balance.
* Medications. Dizziness can be a side effect of certain
medications — such as anti-seizure drugs, antidepressants,
sedatives and tranquilizers. In particular, blood pressure
lowering medications may cause faintness if they lower your
blood pressure too much.
* Anxiety disorders. Certain anxiety disorders may cause
lightheadedness or a woozy feeling often referred to as
dizziness. These include panic attacks and a fear of leaving
home or being in large, open spaces (agoraphobia).
صفحه 16:
* Lowiron levels (anemia). Other signs and symptoms that may
occur along with dizziness if you have anemia include fatigue,
weakness and pale skin.
٠ Low blood sugar (hypoglycemia). This condition generally
occurs in people with diabetes who use insulin. Dizziness
(lightheadedness) may be accompanied by sweating and
anxiety.
* Overheating and dehydration. If you're active in hot weather
or if you don't drink enough fluids, you may feel dizzy from
overheating (hyperthermia) or from dehydration. This is
especially true if you take certain heart medications
صفحه 17:
Risk factors
> Factors that may increase your risk of getting dizzy
include:
* Age Older adults are more likely to have medical
conditions that cause dizziness, especially a sense of
imbalance. They're also more likely to take
medications that can cause dizziness.
* Apast episode of dizziness. If you've experienced
dizziness before, you're more likely to get dizzy in the
future.
صفحه 18:
Complications
* Dizziness can increase your risk of falling and
injuring yourself. Experiencing dizziness while
driving a car or operating heavy machinery
can increase the likelihood of an accident. You
may also experience long-term consequences
if an existing health condition that may be
causing your dizziness goes untreated.
صفحه 19:
Diagnosis
* If your doctor suspects you are having or may have
had a stroke, are older or suffered a blow to the
head, he or she may immediately order an MRI or CT
scan.
٠ Most people visiting their doctor because of dizziness
will first be asked about their symptoms and
medications and then be given a physical
examination.
* During this exam, your doctor will check how you
walk and maintain your balance and how the major
nerves of your central nervous system are working
صفحه 20:
» You may also need a hearing test and balance tests, including:
* Eye movement testing. Your doctor may watch the path of
your eyes when you track a moving object. And you may be
given an eye motion test in which water or air are placed in
your ear canal.
٠ Head movement testing. If your doctor suspects your vertigo
is caused by benign paroxysmal positional vertigo, he or she
may do a simple head movement test called the Dix-Hallpike
maneuver to verify the diagnosis.
In addition, you may be given blood tests to check for infection
and other tests to check heart and blood vessel health
صفحه 21:
* Posturography. This test tells your doctor which parts
of the balance system you rely on the most and
which parts may be giving you problems. You stand in
your bare feet on a platform and try to keep your
balance under various conditions.
* Rotary chair testing. During this test you sit in a
computer-controlled chair that moves very slowly in
a full circle. At faster speeds, it moves back and forth
in avery small arc.
صفحه 22:
Pathophysiology
The peripheral vestibular system is composed of three
semicircular canals, the utricle and saccule, and the vestibular
component of the eighth cranial nerve
Each semicircular canal has a sensory epithelium called the
crista; the sensory epithelium of the utricle and saccule is called
the macule.
The semicircular canals sense angular movements, and the
utricle and saccule sense linear movements.
Two of the semicircular canals (anterior and posterior) are
oriented in the vertical plane nearly orthogonal to each other;
the third canal is oriented in the horizontal plane (horizontal
canal).
صفحه 23:
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صفحه 24:
Semicircular Canals
Ear Vestibulo-
Bones cochlear
Ear Drum Nerve
Cochlea
Ear Canal
صفحه 25:
5 canal
inferior
nerve سس
posterior canal
harizontal canal
صفحه 26:
Movement stimulates
hair cells, which send
a signal through the
sensory nerve
Cupula
Hair cell
صفحه 27:
« The crista of each canal is primarily activated by movement
occurring in the plane of that canal.
* When the hair cells of these organs are stimulated, the signal
is transferred to the vestibular nuclei via the vestibular
portion of cranial nerve VIII
* Signals originating from the horizontal semicircular canal then
pass via the medial longitudinal fasciculus along the floor of
the fourth ventricle to the abducens nuclei in the middle
brainstem and the ocular motor complex in the rostral
brainstem
صفحه 28:
« The anterior and posterior canal impulses pass from the
vestibular nuclei to the ocular motor nucleus and trochlear
nucleus triggering eye movements roughly in the plane of
each canal
٠ key feature is that once vestibular signals leave the vestibular
nuclei they divide into vertical, horizontal, and torsional
components.
* Asaresult, alesion of central vestibular pathways can cause
a pure vertical, pure torsional, or pure horizontal nystagmus
صفحه 29:
« The primary vestibular afferent nerve fibers maintain a
constant baseline firing rate of action potentials
* When the baseline rate from each ear is symmetrical (or an
asymmetry has been centrally compensated), the eyes remain
stationary
* With an uncompensated asymmetry in the firing rate, either
resulting from increased or decreased activity on one side,
slow ocular deviation results
صفحه 30:
By turning the head to the right, the baseline firing rate of the
horizontal canal is physiologically altered, causing an
increased firing rate on the right side and a decreased firing
rate on the left side
The result is a slow deviation of the eyes to the left
In an alert subject, this slow deviation is regularly interrupted
by quick movements in the opposite direction (nystagmus) so
the eyes do not become pinned to one side
In a comatose patient, only the slow component is seen
because the brain cannot generate the corrective fast
components.
صفحه 31:
Physiologic nystagmus Spontaneous nystagmus
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صفحه 32:
* Over time, an asymmetry in the baseline firing rates either
resolves, or CNS compensates for it
— This explains why an entire unilateral peripheral vestibular system can
be surgically destroyed and patients only experience vertigo for
several days to weeks
It also explains why patients with slow-growing tumors affecting the
vestibular nerve, generally do not experience vertigo or nystagmus
صفحه 33:
History of Present Illness
٠ The history and physical examination provide the most
important information when evaluating patients complaining
of dizziness
* The first step is to define the symptom
* For patients unable to provide a more detailed description of
the symptom, the physician can ask the patient to place their
symptom into one of the following categories:
— movement of the environment (vertigo),
— lightheadedness,
— strictly imbalance without an abnormal head sensation
صفحه 34:
Because patient descriptions about dizziness can be unreliable and
inconsistent, other details about the symptom become equally
important
The physician should also ask the following questions:
— Is the symptom constant or episodic,
— are there accompanying symptoms,
— how didit begin (gradual, sudden, etc.),
— were there aggravating or alleviating factors?
— If episodic, what was the duration and frequency of attacks, and were there
triggers?
One key point is that any type of dizziness may worsen with
position changes, but some disorders such as BPPV only occur
after position change.
صفحه 35:
Physical Examination:
General Medical Examination
A brief general medical examination is important
Identifying orthostatic blood pressure can be diagnostic in the
correct clinical setting, so blood pressure should be checked
for this pattern in any patient with orthostatic symptoms.
Orthostatic hypotension is probably the most common
general medical cause of dizziness among patients referred to
neurologists.
Identifying an irregular heart rhythm may also be pertinent.
Other general examination measures to consider include
— avisual assessment (adequate vision is important for balance)
— amusculoskeletal inspection (significant arthritis can impair gait).
صفحه 36:
General Neurological Examination
The general neurological examination is very important in
patients complaining of dizziness, because dizziness can be
— the earliest symptom of a neurodegenerative disorder
— and can also be an important symptom of stroke, tumor,
demyelination of the nervous system
The cranial nerves should be thoroughly assessed in patients
complaining of dizziness
The most important part of the examination lies in evaluating
ocular motor function
صفحه 37:
٠ A posterior fossa mass can impair facial sensation and the
corneal reflex on one side
٠ Assessing facial strength and symmetry is important because
of the close anatomical relationship between the seventh and
eighth cranial nerves
* The lower cranial nerves should also be closely inspected by
observing palatal elevation, tongue protrusion, and trapezius
and sternocleidomastoid strength
صفحه 38:
The general motor examination determines strength in each
muscle group and also assesses bulk and tone
Increased tone or cogwheel rigidity could be the main finding
in a patient with an early neurodegenerative disorder
The peripheral sensory examination is important because a
peripheral neuropathy can cause a nonspecific dizziness or
imbalance
Temperature, pain, vibration, and proprioception should be
Assessed
Reflexes should be tested for their presence and symmetry.
صفحه 39:
One must take into consideration the normal decrease in
vibratory sensation and absence of ankle jerks that can occur
in elderly patients.
Coordination is an important part of the neurological
examination in patients with dizziness because disorders
characterized by ataxia can present with the principal
symptom of dizziness
finger-nose-finger test, the heel-knee shin test, and rapid
alternating movements adequately assesses extremity
coordination
صفحه 40:
Ocular motor exam
The first step in assessing ocular motor function is to search for
spontaneous involuntary movements of the eyes
The examiner asks the patient to look straight ahead while
observing for nystagmus or saccadic intrusions
Nystagmus is characterized by a slow- and fast-phase component
and is classified as either spontaneous, gaze-evoked, or
positional.
The direction of nystagmus is conventionally described by the
direction of the fast phase
Recording whether the nystagmus is vertical, horizontal,
torsional, or a mixture of these provides important localizing
information
صفحه 41:
Spontaneous nystagmus can have either a peripheral or
central pattern
Although central lesions can mimic a “peripheral” pattern of
nystagmus, some very unusual and unlikely circumstances are
required for peripheral lesions to cause “central” patterns of
nystagmus
A peripheral pattern of spontaneous nystagmus is
unidirectional
Peripheral spontaneous nystagmus never changes direction
It is usually a horizontal greater than torsional pattern
صفحه 42:
« Other characteristics of peripheral spontaneous nystagmus
are
— suppression with visual fixation,
— increase in velocity with gaze in the direction of the fast phase,
— decrease with gaze in the direction opposite of the fast phase
* Some patients are able to suppress this nystagmus so well at
the bedside, that spontaneous nystagmus may only appear by
removing visual fixation
صفحه 43:
Gaze Testing
* The patient should be asked to look to the left, right, up, and
down; the examiner looks for gaze-evoked nystagmus in each
position
٠ A few beats of unsustained nystagmus with gaze greater than
30 degrees is called end-gaze nystagmus and variably occurs
in normal subjects
صفحه 44:
Smooth pursuit
Saccades
OKN
VOR suppression
Head -thrust test
Positional testing
Fistula testing
Gait
صفحه 45:
صفحه 46:
Gait
Casual gait is examined for initiation, heel strike, stride length,
and base width
Patients are then observed during tandem walking and while
standing in the Romberg position (with eyes open and closed)
Awidebased gait with inability to tandem walk is
characteristic of truncal ataxia
Patients with acute vestibular loss will veer toward the side of
the affected ear for several days after the event
Patients with peripheral neuropathy or bilateral
vestibulopathy may be unable to stand in the Romberg
position with eyes closed
صفحه 47:
Vestibular neuritis
Acommon presentation to the ED or outpatient clinic is the
rapid onset of severe vertigo, nausea, vomiting, and
imbalance.
The symptoms gradually resolve over several days, but some
symptoms can persist for months.
The etiology of this disorder is probably viral, because the
course is generally benign and self-limited
it occurs in young healthy individuals, and occasionally occurs
in epidemics
صفحه 48:
The key to the diagnosis of vestibular neuritis is recognizing
— the peripheral vestibular pattern of nystagmus
— identifying a positive head-thrust test in the setting of a rapid onset of
vertigo without other neurological symptoms
The course of vestibular neuritis is self-limited, and the
mainstay of treatment is symptomatic
A recent study showed improvement of peripheral vestibular
function, after receiving methylprednisolone within 3 days of
onset, compared to placebo
A formal vestibular rehabilitation program can help patients
compensate for the vestibular lesion
صفحه 49:
BPPV
Benign paroxysmal positional vertigo may be the most
common cause of vertigo in the general population
Patients typically experience brief episodes of vertigo when
getting in and out of bed, turning in bed, bending down and
straightening up, or extending the head back to look up
the condition is caused when calcium carbonate debris
dislodged from the otoconial membrane inadvertently enters
a semicircular canal
Repositioning maneuvers are highly effective in removing the
debris from the canal, though recurrence is common
صفحه 50:
Meniere disease
Meniere disease is characterized by recurrent attacks of
vertigo associated with auditory symptoms (hearing loss,
tinnitus, aural fullness) during attacks
Over time, progressive hearing loss develops
Attacks are variable in duration, most lasting longer than 20
minutes, and are associated with severe nausea and vomiting
The course of the disorder is also highly variable.
For some patients, the attacks are infrequent and decrease
over time, but for others they can become debilitating
صفحه 51:
* Occasionally, auditory symptoms are not appreciated by the
patients or identified by interictal audiograms early in the
disorder, but inevitably patients with Meniere disease develop
these features, usually within the first year
* Meniere disease becomes bilateral in about one-third of
patients
* Endolymphatic hydrops, or expansion of the endolymph
relative to the perilymph, is regarded as the etiology, though
the underlying cause is unclear
صفحه 52:
* The bedside interictal examination of patients with Meniere
disease may identify asymmetrical hearing, but the head-
thrust test is usually normal
* Treatment is initially directed toward an aggressive low-salt
diet and diuretics, though the evidence for these treatments
is poor
صفحه 53:
Vestibular paroxysmia
* Vestibular paroxysmia is characterized by brief (seconds to
minutes) episodes of vertigo, occurring suddenly without any
apparent trigger
* The disorder may be analogous to hemifacial spasm and
trigeminal neuralgia, which are felt to be due to spontaneous
discharges from a partially damaged nerve
* In patients with vestibular paroxysmia, unilateral dysfunction
can sometimes be identified on vestibular or auditory testing
صفحه 54:
most vestibular paroxysmia patients have a favorable course
with conservative or medication management
Medications associated with a reduction in episodes include
carbamazepine, oxcarbazepine, and gabapentin
صفحه 55:
Central Nervous System Disorders
« The key to the diagnosis of CNS disorders in patients
presenting with dizziness are
— the presence of other focal neurological symptoms
— identifying central ocular motor abnormalities
— ataxia
* Because central disorders can mimic peripheral vestibular
disorders, the most effective approach in patients with
isolated dizziness is first to rule out common peripheral
causes
صفحه 56:
Brainstem ischemia
Ischemia affecting vestibular pathways within the brainstem
or cerebellum often causes vertigo
Brainstem ischemia is normally accompanied by other
neurological signs and symptoms, because motor and sensory
pathways are in close proximity to vestibular pathways
Vertigo is the most common symptom with Wallenberg
syndrome
— infarction in the lateral medulla in the territory of the posterior inferior
cerebellar artery (PICA), but other neurological symptoms and signs
(e.g., diplopia, facial numbness, Horner syndrome) are invariably
present
صفحه 57:
Ischemia of the cerebellum can cause vertigo as the most
prominent or only symptom,
Computed tomography (CT) scans of the posterior fossa are
not a sensitive test for ischemic stroke
صفحه 58:
* Abnormal ocular motor findings in patients with brainstem or
cerebellar strokes include:
(1) spontaneous nystagmus that is purely vertical, horizontal, or
torsional,
(2) direction-changing gaze-evoked nystagmus
(3) impairment of smooth pursuit,
— (4) overshooting saccades
صفحه 59:
Rarely, central causes of nystagmus can closely mimic the
peripheral vestibular pattern of spontaneous nystagmus
Patients with brainstem or cerebellar infarction need
immediate attention because herniation or recurrent stroke
can occur
However, because of the rarity of ischemia causing isolated
vertigo, MRI need only be considered in patients with
significant stroke risk factors such as older age, known history
of stroke, transient ischemic attacks (TIAs), coronary artery
disease, or diabetes
صفحه 60:
MS
Dizziness is a common symptom in patients with multiple
sclerosis (MS)
Vertigo is the initial symptom in about 5% of patients with MS
Atypical MS attack has a gradual onset, reaching its peak
within a few days
Milder spontaneous episodes of vertigo, not characteristic of
a new attack, and positional vertigo lasting seconds are also
common in MS patients
Nearly all varieties of central spontaneous and positional
nystagmus occur with MS
صفحه 61:
* Posterior Fossa Structural Abnormalities
٠ Neurodegenerative Disorders
٠ Epilepsy
— Vestibular symptoms are common with focal seizures, particularly
those originating from the temporal and parietal lobes.
— The key to differentiating vertigo with seizures from other causes of
vertigo is that seizures are almost invariably associated with an altered
level of consciousness.
— Episodic vertigo as an isolated manifestation of a focal seizure is a
rarity if it occurs at all.
صفحه 62:
Migraine
Dizziness has long been known to occur among patients with
migraine headaches
benign recurrent vertigo is usually a migraine equivalent
— because no other signs or symptoms develop over time,
— the neurological exam remains normal,
a family or personal history of migraine headaches is
common, as are typical migraine triggers
The key distinguishing factor between migraine and Meniere
disease is the lack of progressive unilateral hearing loss in
patients with migraine
صفحه 63:
* Other types of dizziness are common in patients with
migraine as well, including nonspecific dizziness and
positional vertigo
* The cause of vertigo in migraine patients is not yet known,
but the diagnosis of migraine should be entertained in any
patient with chronic recurrent attacks of dizziness of unknown
cause
* Though the diagnosis of migraine associated dizziness remains
one of exclusion, little else can cause recurrent episodes
without any other symptoms over a long period of time
صفحه 64:
History of Vertige Duration of Vertigo Associated symptoms _ Physical Examination. ی
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صفحه 65:
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صفحه 66:
Ataxia
* Ataxia is incoordination or clumsiness of movement that is not
the result of muscular weakness
* It is caused by vestibular, cerebellar, or sensory
(proprioceptive) disorders
٠ Ataxia can affect eye movement, speech (producing
dysarthria), individual limbs, the trunk, stance, or gait
صفحه 67:
Vestibular ataxia
Vestibular ataxia can be produced by the same central and
peripheral lesions that cause vertigo
Nystagmus is frequently present and is typically unilateral
and most pronounced on gaze away from the side of
vestibular involvement
Dysarthria does not occur
Vestibular ataxia is gravity dependent:
— Incoordination of limb movements cannot be demonstrated when the
patient is examined lying down but becomes apparent when the
patient attempts to stand or walk
صفحه 68:
Cerebellar ataxia
Cerebellar ataxia is produced by lesions of the cerebellum or
its afferent or efferent connections in the cerebellar
peduncles, red nucleus, pons, or spinal cord
Because of the crossed connection between the frontal
cerebral cortex and the cerebellum, unilateral frontal disease
can also occasionally mimic a disorder of the contralateral
cerebellar hemisphere
The clinical manifestations of cerebellar ataxia consist of
irregularities in the rate, rhythm, amplitude, and force of
voluntary movements
صفحه 69:
Characteristics of Vestibular, Cerebellar, and Sensory Ataxia
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