Bedside Diagnosis of Vertigo: Value of the History and Neurological Examination

Vertigo is caused by disturbance of the input or central processing of sensory signals from the vestibular apparatus that provide information regarding the position of the body in space. It is caused either by asymmetric disruption of sensory input from the vestibular organs or asymmetric integration of vestibular input into the central nervous system. Vertigo is readily differentiated from other causes of dizziness by a sensation of motion. A crucial aspect of the management of the emergency department patient with vertigo is the differentiation of vertigo associated with acute stroke syndromes from vertigo due to peripheral causes. Routine computerized axial tomography imaging is insensitive for posterior circulation strokes, so for emergency physicians, the history and neurological examination remain the most useful diagnostic tools. This article emphasizes the history and physical examination in the localization of the lesion in patients with vertigo and offers a rational basis for decisions regarding the need for special neurological imaging and consultation. It also emphasizes subtle findings that may prevent the erroneous diagnosis of peripheral vertigo in the presence of an acute stroke syndrome.     

Placebo-controlled study of short-term hypotensive effect of intranasal ventilation with continuous positive pressure upper respiratory tract therapy in patients with stage I arterial hypertension

AIM: To compare a short-term hypotensive effect of intranasal ventilation with continuous positive airway pressure (CPAP-therapy) in patients with arterial hypertension stage I and placebo-control patients. MATERIAL AND METHODS: The CPAP-therapy and placebo-control groups consisted of 12 young men with arterial hypertension (AH) stage I. They were matched by age, body mass index, smoking habits, arterial pressure 24-h monitoring (APM) and night cardiorespiratory monitoring. Patients of the treatment group received CPAP-therapy (REMstar Choice, Respironics, USA) followed by repeated APM. Patients of the placebo group used a nasal mask without turning on the apparatus. Then a repeated APM was performed. RESULTS: As shown by improved APM data, CPAP-therapy was effective in AH stage I. Positive response was the greatest for systolic and diastolic hypertensive load. CONCLUSION: The above results may serve as an argument in support of a positive relation between elevated resistance of the upper respiratory airways in sleep and systemic AH.     

Treatment of vertigo

Vertigo is the illusion of motion, usually rotational motion. As patients age, vertigo becomes an increasingly common presenting complaint. The most common causes of this condition are benign paroxysmal positional vertigo, acute vestibular neuronitis or labyrinthitis, Ménière's disease, migraine, and anxiety disorders. Less common causes include vertebrobasilar ischemia and retrocochlear tumors. The distinction between peripheral and central vertigo usually can be made clinically and guides management decisions. Most patients with vertigo do not require extensive diagnostic testing and can be treated in the primary care setting. Benign paroxysmal positional vertigo usually improves with a canalith repositioning procedure. Acute vestibular neuronitis or labyrinthitis improves with initial stabilizing measures and a vestibular suppressant medication, followed by vestibular rehabilitation exercises. Meniere's disease often responds to the combination of a low-salt diet and diuretics. Vertiginous migraine headaches generally improve with dietary changes, a tricyclic antidepressant, and a beta blocker or calcium channel blocker. Vertigo associated with anxiety usually responds to a selective serotonin reuptake inhibitor.     

Diazoxide infusion in severe hypertension and hypertensive crisis.

Prompted by reports of hypotension with myocardial ischemia after bolus injection, we restudied the efficacy of diazoxide infusion (5 mg/kg, rate, 15 mg/min) in 35 hypertensive patients. In 20 patients with chronic hypertension, mean arterial pressure of 138 mm Hg was 110 (after 30 min) and 121 (after 8 hr). In 15 patients with hypertensive crisis, there was a fall from 159 to 126 (in 30 min) and 133 mm Hg (after 8 hr), similar to findings in 12 patients with hypertensive crisis treated with a 300-mg bolus injection (159, 130, 140 mm Hg). In the latter, the maximal systolic blood pressure decrease was greater (56 mm Hg, reached in 4 min) than in the 15 patients with hypertensive crisis treated by slow infusion (38 mm Hg in 28 min). Thus, infusion of diazoxide causes a gradual decline of blood pressure and is, in contrast to current opinion, also an effective treatment in hypertensive crisis.     

Vegetative regulation of arterial pressure in patients with arterial hypertension and non-insulin-dependent diabetes mellitus (NIDDM)

72 patients with NIDDM (duration 5.3 +/- 3.1 years) aged 41-60 years were examined. They had also mild or moderate hypertension (duration 12.1 +/- 4.5). Control groups consisted of 15 NIDDM patients free of hypertension, 15 hypertensive patients without diabetes, 15 healthy subjects. All the patients have undergone 24-h monitoring of arterial pressure (APM) and computed cardiointervalography (CIG). As shown by CIG, hypertensive patients with NIDDM had sympathotonia which resulted from hypofunction of parasympathetic and hyperfunction of the sympathetic nervous systems. APM demonstrated enhanced variability of arterial pressure and its inadequate fall at night in patients of this group and normotensive patients with diabetes.     

Vertigo and dizziness related to migraine: a diagnostic challenge

Vertigo and dizziness can be related to migraine in various ways: causally, statistically or, quite frequently, just by chance. Migrainous vertigo (MV) is a vestibular syndrome caused by migraine and presents with attacks of spontaneous or positional vertigo lasting seconds to days and migrainous symptoms during the attack. MV is the most common cause of spontaneous recurrent vertigo and is presently not included in the International Headache Society classification of migraine. Benign paroxysmal positional vertigo (BPPV) and Ménière's disease (MD) are statistically related to migraine, but the possible pathogenetic links have not been established. Moreover, migraineurs suffer from motion sickness more often than controls. Persistent cerebellar symptoms may develop in the course of familial hemiplegic migraine. Dizziness may also be due to orthostatic hypotension, anxiety disorders or major depression which all have an increased prevalence in patients with migraine.     

伴单侧外周前庭受损的头晕/眩晕患者的临床分析

目的:探讨伴单侧外周前庭受损(UPVD)的头晕/眩晕患者的病因学、临床特征及相关危险因素。方法:连续收集我院神经科门诊就诊的伴UPVD的头晕/眩晕患者148例为病例组,同期收集我院健康体检门诊年龄、性别相匹配的187例健康人为对照组。收集2组研究对象的基线资料,分析伴UPVD的头晕/眩晕患者的病因及伴发疾病分布,应用多元Logistic回归分析伴UPVD的头晕/眩晕患者的独立危险因素。结果:148例伴UPVD的头晕/眩晕患者年龄9~86岁,男:女约为1:2。可以头晕(74.3%)或眩晕(25.7%)起病,分原发性(23.0%)和继发性/伴发性(77.0%)。原发性伴UPVD的头晕/眩晕患者包括急性原发单侧前庭病、发作性原发单侧前庭病、慢性原发单侧前庭病;继发/伴发性伴UPVD的头晕/眩晕患者包括良性阵发性位置性眩晕、持续性姿势-感知性头晕、可能的迷路卒中、慢性缺血性单侧前庭病可能、内耳缺血性发作性前庭病变可能、前庭性偏头痛、梅尼埃病、前庭神经元炎及迷路震荡。多元Logistic回归分析提示高血压、高脂血症是伴UPVD的头晕/眩晕患者的独立危险因素(P<0.05)。结论:神经科门诊伴UPVD的头晕/眩晕患者常伴有动脉粥样硬化危险因素。病因诊断较为困难,病因不明最为多见,其次多因伴发良性阵发性位置性眩晕、持续性姿势-感知性头晕和可能的迷路卒中而就诊。     

Diagnosis and management of vertigo

Vertigo is an illusion of rotation due to a disorder of the vestibular system, almost always peripheral. In the history it must be distinguished from pre-syncope, seizures and panic attacks. A single attack of acute, isolated spontaneous vertigo lasting a day or more is due either to vestibular neuritis or cerebellar infarction; distinguishing between the two requires mastery of the head impulse test. Recurrent vertigo is mostly due to benign paroxysmal positioning vertigo (BPPV), Meniere's disease or migraine. With a good history, a positional test, an audiogram and a caloric test, it is usually possible to distinguish between these. BPPV is the single most common cause of recurrent vertigo and can usually be cured immediately with a particle repositioning manoeuvre. Posterior circulation ischaemia very rarely causes isolated vertigo attacks and when it does the attacks are brief and frequent and the history is short.     

Vertigo.

Vertigo reflects dysfunction in the vestibular system. Any disease state which changes the firing frequency of a vestibular end-organ and which produces unequal neural input to the brainstem causes vertigo. Caloric stimulation mimics acute end-organ dysfunction and helps establish the diagnosis.     

What is vertigo?

Vertigo is one of the types of dizziness with dysequilibrium, presyncope and lightheadedness. But what does vertigo mean? Vertigo indicates a sensation of false movement (generally described like a rotation) but sometimes the patient can describe it like a sensation of tilt. Instead, the word dizziness indicates a sensation of disturbed relation to surrounding objects in space with feelings of rotation or whirling characteristic of vertigo as well as non-rotatory swaying, weakness, faintness and unsteadiness characteristic of giddiness. In our review we describe, after brief considerations about functional anatomy of the vestibular system, the most important cause of vertigo considering the duration of the symptom; moreover we underline the importance of anamnesis and of the objective examination for a correct differential diagnosis of a dizzy patient. As to objective examination we describe the most important characteristics of nystagmus, that is the only objective sign in vertigo, of central and peripheral origin. At last we consider the most efficacious therapies, like as medications (specific and aspecific), surgery (conservative and destructive) and rehabilitation, in relation the characteristics and the causes of vertigo.     

Clinical evaluation of changes in alimentary motivation and arterial pressure in patients with essential hypertension

A study was made of the main signs of food motivation in 132 patients with stages I-III essential hypertension on the basis of analysis of a special questionnaire: the patients were interviewed in hospital and after discharge (a total of 40-46 days) to reveal the effect of raised arterial pressure on food behavioral reactions. Clinical signs of a hypertensive crisis were noted in 87 patients, in 45 patients raised arterial pressure was not accompanied by a crisis. In 82% of the cases hypertensive reactions produced a marked effect on the manifestations of food motivation. Anorectic reactions prevailed in the first 3-6 days in 98 of 109 patients (80.7%). These reactions were pronounced and prolonged in the patients with normal body mass. During the second week hyperphagic reactions prevailed in 68% of the cases, their frequency, expression and period were greater in the patients with concomitant obesity. The revealed time course of food behavioral reactions reflected the phase of food motivation in patients with arterial hypertension: hypertensive anorexia followed by post-hypertensive hyperphagia for 2-3 weeks.     

Myocardial status, hemodynamics and pressor humoral substances in patients with bronchial asthma and arterial hypertension

The analysis of data obtained for 101 bronchial asthma (BA) sufferers with hypertension and 30 normotensive patients demonstrated the dependence of arterial hypertension in BA patients on a significant increase in the systemic peripheral resistance, pulmonary circulation pressure, diastolic dysfunction, reduced cardiac output, pulse brain filling as well as on elevated serotonin level and monoamine oxidase hyperactivity. The findings provided additional information on the causes and triggering mechanisms of arterial hypertension in BA patients, are helpful in design of antihypertensive treatment and the disease prevention.     

Hypertensive crises

The key points of this article are: (1) A hypertensive crisis is present when markedly elevated blood pressure is accompanied by progressive or impending acute target organ damage. (2) Most instances of very elevated blood pressure encountered in the office setting will not be crises and will not require acute reduction of blood pressure. (3) Hypertensive crises are largely preventable and often result from inadequate management of hypertension or poor adherence to therapy. (4) Effective triage of patients into categories of severe hypertension, hypertensive urgency, and hypertensive emergency through an expeditious history, examination, and testing should guide therapy. (5) Hypertensive urgency is managed with oral medications and usually on an outpatient basis; a hypertensive emergency warrants intensive care unit admission and parenteral therapy. (6) Ensuring adequate follow-up after treatment of very elevated blood pressure is a critical step that is often mishandled.     

耳鼻喉科门诊1812例眩晕患者的临床特点分析

目的分析耳鼻喉科门诊就诊眩晕患者的基本数据,探讨门诊眩晕患者的临床特点,为眩晕处置方案研究提供流行病学依据。方法采用回顾性研究方法,分析北京友谊医院耳鼻喉科门诊首诊为眩晕的1 812例患者的人口学特征和临床测试结果。结果眩晕发病人数男女比例为1∶2.07,年龄14~91岁,平均年龄为(54.63±13.31)岁,其中50~59岁年龄段患者最多,占36.20%。良性阵发性位置性眩晕(BPPV)在所有引起眩晕的病因中占41.61%,中枢性眩晕占38.19%。相较听力下降以及前庭功能下降,伴有体位变化的眩晕患者有3.92倍的风险被诊断为外周性眩晕。结论眩晕患者中女性多于男性,50~59岁是高发年龄段,良性阵发性位置性眩晕在所有病因中最为常见。伴有体位变化相关的眩晕患者,常见于外周性眩晕。     

Systematic approach needed to establish cause of vertigo

Vertigo can be defined as an illusion or hallucination of movement. The control of balance is complicated. Vertigo can be caused by many different pathologies, some of which are potentially life threatening. An important differentiation is whether the symptoms of vertigo originate from a central or peripheral origin. Clues to a central origin are other brainstem symptoms or signs of acute onset such as headache, deafness and other neurological findings. These patients warrant urgent referral and investigation. Red flags in patients with vertigo include: headache; neurological symptoms; and neurological signs. It is useful to categorise vertigo into acute and chronic. The former usually has a single mechanism whereas chronic dizziness is often multifactorial. History is usually the most important part of the assessment. Key questions should be asked and it is vital to establish if the patient is suffering from vertigo or some other complaint such as anxiety or syncope. A neurological and otological examination should be performed, appropriate to the history. Assessment of gait and posture is crucial. If the patient has positional vertigo then a Hallpike test should be performed. Visual acuity should be checked as vision is a vital part of the balance system. The cranial nerves should be tested in particular eye movements for any ophthalmoplegia pointing to focal cranial nerve pathology and for nystagmus. The rest of the neurological examination should exclude evidence of central disease, in particular cerebellar disease, and neuropathy. If syncope is suspected it is wise to perform an extensive systemic examination in particular lying and standing BP, and cardiovascular and respiratory system assessments.     

The dizzy patient. A practical approach to management

Dizziness can generally be divided into true vertigo and pseudovertigo (giddiness or light-headedness). The most common causes of pseudovertigo are hyperventilation, orthostatic hypotension, and multisensory deficits of older patients. Of the many types of true vertigo, only a few are caused by serious structural disorders of the brainstem, and these can usually be recognized by their temporal profile and concomitant symptoms and signs. Most cases of vertigo are caused by peripheral vestibular disorders that are self-limiting. Treatment is directed toward control of the acute autonomic symptoms and labyrinthine suppression until physiologic compensation takes place. Patients with vertigo that is prolonged, chronic, and recurrent may be helped by exercises designed to hasten or assist recovery of compensatory mechanisms.     

Target organ involvement in hypertension: a realistic promise of prevention and reversal

The major message from this discussion is that the end points from hypertensive disease (stroke, CHD, and hypertensive emergencies) are now preventable. Cardiac failure and ESRD, however, two exceedingly common end points from long-standing hypertension, remain as major disabilities and causes of death. The former is the most common cause of hospitalization in industrialized societies; hypertension and diabetes mellitus are the most common causes of the latter. The mechanisms of risk of these target organ diseases is not LVH per se, or the elevated arterial pressure alone in the kidney, but the coronary and renal ischemia, organ fibrosis, and, perhaps, apoptosis. Present day therapy now can effectively reverse these costly (economically and by human suffering) complications. Recent experimental studies suggest that, when used early enough, these newer pharmacologic agents may even prevent their occurrences and consequences. The very practical lesson from these experiences is that early detection and treatment of hypertension, effective control of arterial pressure, and the suppression of the underlying disease mechanisms markedly reduce the now increasing prevalence of both cardiac and renal failure.     

乌拉地尔与酚妥拉明治疗重度肾实质性高血压的效果比较

目的 :比较乌拉地尔与酚妥拉明对重、急症肾实质性高血压的治疗效果。方法 :对 2 7例重、急症肾实质性高血压患者分别使用乌拉地尔和酚妥拉明进行治疗。观察用药后的临床表现 ,测定用药后 5、10、30、6 0、12 0min时的收缩压 (SBP)、舒张压 (DBP)、心率 (HR)。结果 :两治疗组在     

Vertebral artery dissection presenting as isolated vertigo

Vertigo is not an uncommon presentation to the emergency department. It is most commonly caused by benign peripheral processes, such as inner ear or vestibular nerve dysfunction, but can be due to central brain lesions. In this report, we present a central cause of isolated vertigo: brainstem infarct secondary to vertebral artery dissection (VAD). VAD is increasingly being recognised as an important cause of stroke in young people. We discuss the important features that need to be elicited to distinguish central from peripheral disease and the relevance of VAD.