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Dizziness Dizziness Presentation Transcript

  • DIZZINESS Alina Valdes, M.D.
  • Causes
    • Vertigo – rotational sensation
      • Peripheral or central vestibular disorders
    • Presyncope – lightheadedness, impending fainting, dimming of vision
      • Systemic or cardiovascular disorders producing impaired cerebral blood flow
    • Instability
    • Disequilibrium – impaired balance or gait
      • Neurologic disorders producing disordered sensory input into the brain
    • Hyperventilation
  • Diagnosis
    • Causes of presyncope
      • Cardiac arrhythmia
      • Outflow obstruction
      • Orthostatic hypotension
    • Symptoms of presyncope
      • Wooziness, giddiness
      • Disequilibrium without true vertigo
      • Global weakness
      • Dimming of vision
    • Cardiac causes
      • Events occurring when patient laying down or exercising
    • Orthostatic hypotension
      • Positional BP exam
    • Hyperventilation
      • Induce symptoms by hyperventilating for 3 minutes
  • Vertigo
    • Illusory sense of unidirectional rotational movement
    • With eyes open
      • Environment moves in direction opposite slow component of nystagmus
    • With eyes closed
      • Feel turning or whirling sensation in space
    • Peripheral disorders
      • Sudden onset
      • May be disabling, e.g., vomiting
      • Nystagmus always present
      • Rarely life-threatening
    • Central nervous system disorders
      • Nonparoxysmal onset
      • Symptoms may be mild
      • Nystagmus may be present or absent
      • Symptoms may progress to CNS dysfunction (e.g. MS) or death (e.g. basilar artery stroke)
    • Nystagmus
      • Present if vertigo is peripheral in origin
      • Fast phase directed away from affected ear
      • Not present if vertigo is central in origin
      • If present but disassociation of nystagmoid movements between two eyes or if purely vertical, central cause present
  • Peripheral Vertigo
    • Acute peripheral vestibular disorders
      • Vertigo, nausea, and vomiting
      • Ill-appearing
      • Lie on one side with affected ear up
      • Reluctant to move head
      • Horizontal nystagmus with fast phase away from affected ear always present
    • Vestibular neuronitis
      • Repetitive attacks of peripheral vertigo without auditory dysfunction
    • Labyrinthitis
      • Severe acute vertigo with autonomic symptoms in setting of otitis or viremia
    • Peripheral vestibulopathy
      • Recurrent attacks of vertigo in any age group with other neuro symptoms but a normal neuro exam
    • Positional vertigo
      • Extremely common position or rolling over in bed
      • Caused by freely moving debris within
      • Moving from upright to recumbent semicircular canals of vestibular system
      • Can be treated by repositioning maneuvers
    • Meniere’s disease
      • Uncommon disorder
      • Vertigo, progressive unilateral hearing loss, and tinnitus
    • Benign paroxysmal positional nystagmus
      • Most common type of positional nystagmus
      • Vertigo and nystagmus disappear with repeated positioning
      • Diagnosis made clinically: abrupt-onset positional vertigo, nausea, and disequilibrium
    • Acoustic neuromas
      • Extremely rare
      • Vertigo, hearing loss, tinnitus, and unsteadiness
  • Central Vertigo
    • Cerebrovascular disease
      • Vertebral vascular ischemia : MRI may show ischemia in brain stem or cerebellum
      • Cerebellar hemorrhage or infarction : sudden onset dizziness, vomiting, disequilibrium, and truncal ataxia; nystagmus uncommon
      • Cerebellar swelling : can produce brain stem compression and death; surgical decompression may be life-saving
    • Other conditions
      • Demyelinating disease, mass lesions, basilar migraines, and epilepsy
  • Treatment
    • Peripheral vestibular suppressants
      • Meclizine
      • Dimenhydrinate
      • Promethazine
    • Central vestibular suppressants
      • Low-dose diazepam or oxazepam
      • Antiemetics as needed
    • Meniere’s disease
      • Treated with diuretics
      • Spontaneous remissions common
      • Surgical ablation only in severe persistent cases
    • Migraine
      • Respond to antimigraine therapy
    • Vertebrobasilar insufficiency
      • Aspirin or ticlopidine