گیجی و سرگیجه

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Dizziness & vertigo 

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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. 

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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 

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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: 

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Sudden, severe headache Chest pain Difficulty breathing Numbness or paralysis of arms or legs Fainting Double Rapid or irregular heartbeat Confusion or slurred speech Stumbling or difficulty walking Ongoing vomiting Seizures A sudden change in hearing Facial numbness or weakness 

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ص02 * )]( ‏ودف ححا جوع وو‎ possible causes, iodo ‏له وه موی رهطم عوج عجووز‎ ۱ posed by ua ‏رولیت‎ hells ‏رم‎ suck us poor ‏راهان‎ Peto or isu. 

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ke seuse oP ‏مت نو لام لا من عمج وا‎ the ‎oP p seusory systew. reve tochide |‏ وم و ‎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 

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* 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. 

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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. 

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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. 

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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. 

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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. 

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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. * 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 

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Other causes of dizziness ٠ 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 

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+ Low iron levels (anemia). Other signs and symptoms that may occur along with dizziness if you have anemia include fatigue, weakness and pale skin. * 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 

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Risk Pactors » 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. * A past episode of dizziness. If you've experienced dizziness before, you're more likely to get dizzy in the future. 

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* 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. 

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Oincyuosis * 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. * 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 

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» 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. + Head movement testing. If your doctor suspects your vertigo is caused by benign paroxysmal positional vertigo, he or she may doa 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 hloond veccel health 

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٠ 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 a very small arc. 

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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). 

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0 Duets Nav=emegsier 0106 Round ‏لمم‎ ‎Protein = 126 ‏الاو‎ widow 

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Semicircular Canals Ear Vestibulo- Bones cochlear Nerve Cochlea Ear Canal 

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Movement stimulates hair cells, which send a signal through the sensory nerve Cupula Hair cell Stationary 

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* 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 

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+ 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 * key feature is that once vestibular signals leave the vestibular nuclei they divide into vertical, horizontal, and torsional components. ٠ Asa result, a lesion of central vestibular pathways can cause a pure vertical, pure torsional, or pure horizontal nystagmus 

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+ 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 

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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 adenerate the corrective fact camnonentc_ 

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Physiologic nystagmus ‘Spontaneous nystagmus قر دم 2 100 

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* 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 

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History of Present Illness + 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 

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+ 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 did it 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. 

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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 - a visual assessment (adequate vision is important for balance) - a musculoskeletal inspection (significant arthritis can impair gait). 

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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 

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+ A posterior fossa mass can impair facial sensation and the corneal reflex on one side * 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 

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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. 

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* 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 

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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 

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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 

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* 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 

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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 - A few beats of unsustained nystagmus with gaze greater than 30 degrees is called end-gaze nystagmus and variably occurs in normal subjects 

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Smooth pursuit Saccades OKN VOR suppression Head -thrust test Positional testing Fistula testing Gait 

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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) A widebased 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 

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Vestibular neuritis A common 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 

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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 

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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 

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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 

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* 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 

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+ 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 

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Vestibular paroxysmia ٠ 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 ٠ In patients with vestibular paroxysmia, unilateral dysfunction can sometimes be identified on vestibular or auditory testing 

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* 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 

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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 

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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 ٠ 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 

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* 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 

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+ 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 

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+ 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 

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MS Dizziness is a common symptom in patients with multiple sclerosis (MS) Vertigo is the initial symptom in about 5% of patients with MS A typical 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 

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۱ + Neurodegenerative Disorders ۰ 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. 

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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 

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+ 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 

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Physical Examination “Peripherals nystagmus, poste head tr tt Imbalance Characteristic postionally triggered burt of nystagmus Unilateral low frequency hearing loss Usually normal stags triggered by loud esse chang History of Vertige Duration of Vertige Associated symptoms Nausea, inbslonce Unilateral ear fullness, ‘anni, heating lows, “Tinnitus, hearing loss Hearing loss, i Days to weeks <1 minute Hours Seconds Seconds Single protonged ‏بدت‎ Postionally triggered ‘episodes May be wiggered by salty foods ‘Abrupt onset: ‘spontaneous or Postionally wlggered Triggered by sound 3 ‏ما1‎ newts 3 1 vestioular paroxysmla Perlymph fistula 

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‎j‏ ی ‎Abrupt ons ‘Stoke stahous Brainstem, cerebellar Spontaneous "central"‏ و ‎Spontaneous TA, usually minutes iystagmus; gaze-evoked‏ ‎nystagmus sly Focal‏ ‎neurologic signs‏ ‎Ms, Subacute onset Minutes to weeks Unilateral visual loss, “Central” types or rarely‏ ‎aiplepi, peripheral" types af‏ ‎Ingoordination, ataxia spontaneous or positional ‏نا‎ aly eter focal ‎neurologic signs Neurodagenerative May be spontaneaus Minutes to hours taka “central” types of spontaneous disorders ‘oF postonally or positional nystagmus ‏و‎ gaze-evoked nystagmus: ferebelar, extrapyramidal and ‘rontal signe Migraine Onset usually Seconds to days Headache, visual aura, Normal intericta exam etl ‘oclated with ] examination may show typical migraine “peripheral” or “central” types agers of spontaneous of positional rystagmus Familial ataxia Acutesubacuto Hours taxa “central” types of spontaneous syndromes onset: usualy ‘or positional nystagmus Iiggered by sess, Fetal or even iterctal ares, oF ‘gaze-evoked nystagmus exctement Stawa: galt dsorders ‎ 

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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 + Ataxia can affect eye movement, speech (producing dysarthria), individual limbs, the trunk, stance, or gait 

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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 

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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 

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