4- Vertigo and Syncope Flashcards
What is defined as a sensation of abn movement (spinning, tumbling, falling forward/ backward) when there is no motion and what is it often a/w?
Vertigo- a symptom
A/w nystagmus and postural instability
What is defined as a sense of imbalance (losing balance w/o sensation of movement) and is characterized by imbalance and gait difficulties?
Disequilibrium
What is defined as vague and nonspecific dizziness?
Lightheadedness
What is defined as a feeling of impending faint or LOC and is generally a/w cardiac etiology?
Presyncope
Peripheral vs central causes of syncope imply a lesion where?
Peripheral- vestibular lesion
Central- central lesion
What is the suspected cause of vertigo if sudden/ acute onset, and horizontal or torsional nystagmus?
Would you expect ear sxs and/ or neuro sxs?
Peripheral
YES ear sxs, NO neuro sxs
What is the suspected cause of vertigo if gradual/ progressive onset, associated HA or N/V and vertical, nonfatigable nystagmus?
Would you expect ear sxs and/ or neuro sxs?
Central
NO ear sxs, YES neuro sxs
What are a few serious causes of vertigo that must be ruled out as part of a workup for a “dizzy” pt?
CV disease
MS
Acoustic neuroma
PE of “dizzy” pt should include what specifically?
(in additional to general PE)
Check BP for orthostasis
How is nystagmus characterized and referred to?
Slow drift in one direction followed by fast response in opposite direction
Referred to by direction of fast component
Horizontal nystagmus indicates what cause?
Peripheral or metabolic
Horizontal/ torsional nystagmus indicates what cause?
Peripheral or positional
Vertical nystagmus indicates what cause?
CNS
What dx study is the most helpful for BPPV as it reproduces vertigo and horizontal nystagmus?
(BPPV: benign paroxysmal positional vertigo)
Dix-Hallpike maneuver
(quickly lower seated pt to supine position w/ head turned to right w/ head to 30˚ below horizontal, observe for nystagmus, repeat w/ head turned to left)
What dx studies would you use to assess for vestibular function/ ocular motility?
ENG (electronystagmography) or VNG (videonystagmography)
What dx study would you use to test the vestibulo-ocular reflex?
Caloric testing- CN III, VI
What is considered a normal result for caloric testing?
Cold water: eyes deviate ipsilateral and nystagmus beats away to opposite side
Warm water: eyes deviate contralateral and nystagmus beats toward same side
COWS
What is considered an abnormal result for caloric testing and what does it indicate?
Vestibular paresis (absent thermally induced nystagmus) → pathology in labyrinth on irrigated side
What is the most common cause of vertigo?
BPPV
(secondary to canalithiasis)
Pt w/ hx of prolonged bedrest following head trauma presents with transient (< 1 min) episodes of vertigo a/w changes in head position and no hearing changes. What are you concerned for?
BPPV
What would you note with BPPV sxs with repeated Dix-Hallpike test?
Fatigue
What is the management for BPPV?
Pt EDU/ reassurance (self-limited weeks to months)
Particle repositioning maneuvers
OT/ positional exercises
What vestibular suppressant meds can be used in the tx of vertigo?
(not effective for BPPV)
Anticholinergics (scopalamine)
Antihistamines (meclizine, dimenhydrinate)
What condition is often preceded by a viral infection (URI)?
Vestibular neuritis
(vestibular neuronitis = vestibular n. only
labyrinthitis = vestibular & cochlear n.)
Pt presents with single attack of severe vertigo (sxs last days- 1 week), N/V, gait instability, and NO associated tinnitus or hearing loss. Hx of viral URI. What are you concerned for?
Vestibular neuritis
(labyrinthitis if (+) hearing loss)
How is vestibular neuritis diagnosed?
(+) head thrust test = nystagmus
(+) caloric testing = vestibular paresis
No CNS deficits, N audiogram
What is the management for vestibular neuritis?
Symptomatic tx, self-limited
What condition is thought to be secondary to endolymphatic hydrops?
Meniere disease
Pt presents with sudden onset attacks of episodic vertigo, tinnitus, and fluctuating hearing loss. Associated sxs include ear fullness, N/V. Audiogram shows sensorineural hearing loss. What are you concerned for?
Meniere disease
How does hearing loss progress with Meniere disease?
Becomes irreversible → low tones lost first
Attacks of vertigo stop when deafness complete
What is the tx for an acute attack of Meniere disease?
Bed rest, symptomatic care
What is used for prophylactic management of Meniere disease?
Low salt diet, diuretics
Limit caffeine, nicotine, EtOH, MSG
What is the tx for refractory Meniere?
Surgery
What is defined as an abn connection between the perilymph and the middle ear?
Perilymphatic fistula
Pt presents with hearing loss and tinnitus and hx of head trauma/ barotrauma. What are you concerned for and how would you confirm your suspected dx?
Perilymphatic fistula
Dx with pneumatic otoscopy
What is the management for perilymphatic fistula?
Bedrest, hydration, sx tx, surgery
What would be considered red flags in vertigo? (4)
Neuro deficit
Ipsilateral hearing loss
Gait abn
Direction changing nystagmus
What is defined as a sudden, transient LOC w/ spontaneous recovery, and is a/w loss of postural tone due to diminished cerebral BF?
Syncope- a symptom
What syncope etiology is a/w a higher risk of death?
Cardiac
What prodromal sxs are consistent w/ vasovagal syncope?
Lightheadedness
Facial pallor
Diaphoresis
Nausea
(other general: uneasiness/ apprehension, visual blurring, CP/ SOB, HA/ focal neuro sxs)
What BP changes are considered (+) for othostasis?
P systole > 20 mmHg
P diastole > 10 mmHg
What provacative test is indicated if recurrent episodes of unexplained vasovagal syncope and no hx of cardiac disease?
Tilt table
Abn: exaggerated drop in BP, dizziness/lightheadedness +/- drop in HR
(normal: minimal drop in BP/increase in HR)
What test is indicated for recurrent episodes of syncope with negative work-up and used if NO prior hx of carotid sinus syncope?
Carotid sinus massage
Palpate/auscultate for carotid bruits → STOP if present → massage carotid sinus for 5-10 sec → (+) if sxs reproduced and peroid of asystole > 3-5 sec or drop in BP > 50 mmHg
What are contraindications for carotid sinus massage?
Hx of TIA/ stroke w/i past 3 months
Carotid bruits
Pt presents with episodes of presyncope/ syncope and associated palpiations with NO prodrome. EKG shows sinus node dysfunction and AV block. What are you concerned for?
Cardiac syncope due to bradyarrhythmia
Pt presents with episodes of presyncope/ syncope and associated palpiations with NO prodrome. EKG shows SVT, Wolff Parkinson White, and VT. What are you concerned for?
Cardiac syncope due to tachyarrhythmia
What is the most common cause of obstructive cardiac syncope?
Aortic stenosis (a/w exertion)
(can also be due to aortic dissection)
What type of syncope is neurally mediated, and due to loss of SNS tone or sudden ↑ in PNS tone?
Reflex syncope
What is the most well-known reflex syncope and is aka “common faint”?
Vasovagal syncope
(attacks solitary, no long term rx needed)
What type of syncope is typically seen in middle aged/ eldery pts w/ athersclerotic vascular disease and is due to the carotid sinus being abnormally responsive to pressure (ex. tight shirt collor/shaving)?
Carotid sinus syncope
What is the tx for carotid sinus syncope?
Cardiac pacemaker
What is defined as a syncopal episode after emptying a distended bladder and is seen after excess fluid ingestion?
Micturition syncope
What type of syncope is seen with severe coughing leading to increased intrathoracic pressure and decreased CO and may be a/w with barrel chest/ COPD or children w/ asthma?
Tussive syncope
When is orthostatic (postural) hypotension more worrisome?
Delayed sxs
(a few moments to several min after standing)
(orthostatic hypotension worsened by autonomic/ peripheral neuropathies and debilitation)
What is the management of orthostatic hypotension?
Avoid volume depletion, behavior mod
(slow changes in position, dorsiflexion of feet/ handgrip exercises prior to standing, Jobst stockings)
Pt presents with vertigo, syncope, +/- diplopia, dysarthria, and ataxia. You eval for sxs with arm exertion and look for difference in pulses in the UEs. What are you concerned for?
Subclavian steal syndrome
(stenosis of subclavian artery near origin, reversal in ipsilateral vertebral artery = decreased cerebral perfusion)
What is indicated if syncope remains unexplained after workup?
Benign w/ good prognosis
