Dizziness and Syncope - Strowd Flashcards
- Neurobiology underlying dizziness is poorly ____
- Network involved is ___and ___
There are three regions of the body involved in balence and coordination.
- Neurobiology underlying dizziness is poorly localized
- Network involved is dynamic and interconnected
•Systematic approach to pin-pointing dizziness:
___
___
___
___
•Systematic approach to:
•Description
•Terminology
•System
•Evaluation
Approach to Dysequilibrium
Description:
- Drunkenness
- Off balance, imbalance, unsteady
Approach to Patients - Do a Cerebellar Exam
- Look for signs of cerebellar dysfunction by doing a cerebellar exam.
- Start by looking for ___ by having patient do a __-___-___ or __-___-___test. If the patients has problems, this could be an issue caused by an affected ___ ___)
- Look for __ ataxia (body does not want to sit upright when standing or sitting, patient has a tandem gait, and has problems walking in a straight line). These issues stem from an affected ___.
If you find these issues, then it necessitates imaging: MRI Brain
Approach to Dysequilibrium
Description:
- Drunkenness
- Off balance, imbalance, unsteady
Approach to Patients - Do a Cerebellar Exam
- Look for signs of cerebellar dysfunction by doing a cerebellar exam.
- Start by looking for dysmetria by having patient do a finger note finger or heel shin heel test. If the patients has problems, this could be an issue caused by an affected lateral hemispheres)
- Look for trunkal ataxia (body does not want to sit upright when standing or sitting, patient has a tandem gait, and has problems walking in a straight line). These issues stem from an affected ___.
If you find these issues, then it necessitates imaging: MRI Brain
Syncope:
•Definition:
•Sudden onset of loss of _____ (syncope) or near loss of consciousness (____)
•Etiology
- ___ (cardiogenic)
- ___ (aorta, carotids)
- ___ tone
Can be caused by reduced blood flow to the brain or reduced ___.
Syncope:
•Definition:
•Sudden onset of loss of consciousness (syncope) or near loss of consciousness (pre-syncope)
•Etiology
- Heart (cardiogenic)
- M. Vessels (aorta, carotids)
- Vascular tone
Can be caused by reduced blood flow to the brain or reduced preload
Cardiogenic Syncope:
- Reduction in ___ flow ___ of the heart
- Reduced blood flow to ___, ___activating system (a diffuse network of nerve pathways in the brainstem connecting the spinal cord, cerebrum, and cerebellum, and mediating the overall level of consciousness), ___ hemispheres
- Manifests with ___ (presyncope/syncope)
If you have a patient with syncope, first think about:
- problems with the ___, such as ___, ____, QTc abnormality
How will you evaluate this heart?
- Electrocardiogram (ECG)
- Prolonged ECG (Holter, etc)
Transthoracic echocardiogram
Cardiogenic Syncope:
- Reduction in blood flow out of the heart
- Reduced blood flow to brain, reticuloactivating system (a diffuse network of nerve pathways in the brainstem connecting the spinal cord, cerebrum, and cerebellum, and mediating the overall level of consciousness), bilateral hemispheres
- Manifests with fainting (presyncope/syncope)
If you have a patient with syncope, first think about:
- problems with the heart, such as bradycardia, obstruction, QTc abnormality
How will you evaluate this heart?
- Electrocardiogram (ECG)
- Prolonged ECG (Holter, etc)
Transthoracic echocardiogram
Pre-syncope can also be caused by vascular tone:
There are two categories:
- ___-vagal
- ___-vagal
1. VASO-vagal
- Also referred to as ____ syncope
- It is a ____-mediated cardio___ signal resulting from imbalance of ___/___tone
- It results from systemic ____ without reflex ___, often as a result of position change (i.e. standing)
- Caused by dehydration, ____-induced (anti___tensives), ____ neuropathy
How would we evaluate this?
- __ ___ pressure
- __ ___ testing
2. VAGO-vagal
- Post-___ (___) syncope
- ____ syncope
- Valsalva
- Also called: __ syncope
- Results from ___ in vagal tone, ___cardia and relative (transient) reduction in CPP (cerebral perfusion pressure)
- Management involves interventions to avoid situations that may induce___ , and reduce ___ drive
Pre-syncope can also be caused by vascular tone:
There are two categories:
- VASO-vagal
- VAGO-vagal
1. VASO-vagal
- Also referred to as neurocardiogenic syncope
- It is a neurally-mediated cardioinhibitory signal resulting from imbalance of parasympathetic/sympathetic tone
- It results from systemic hypotension without reflexive tachycardia, often as a result of positional change (i.e. standing)
- Caused by dehydration, medication-induced (antihypertensives), autonomic neuropathy
How would we evaluate this?
- Orthostatic blood pressure
- Tilt Table testing
2. VAGO-vagal
- Post-tussive (cough) syncope
- Micturition syncope
- Valsalva
- Also called: situational syncope
- Results from increase in vagal tone, bradycardia and relative (transient) reduction in CPP
- Management involves interventions to avoid situations that may inducesyncope, and reduce parasympathetic drive
Vertigo is involved with the vestibular nerve.
Vertigo gives the illusion of:
- Whirling
- Tilting
- Moving
- Spinning
The vestibular nerve is paried with the cochlear nerve to form the vestibulocochlear nerve. They then relay all the info to the vestibular ___ in the brain stem. From the nuclei, there are three destinations:
- ___ ___ of the ___ - receives info from the vestibular nuclei and helps with coordination of eye and head movements together.
- ___ and ___ nerves - help with movement of eyes
- ____ system (tract) - a descending white matter tract which talks to the reflex system of the body which helps keep the body keep up with the head.
The peripheral system is made up of the___ apparatus and ___ nerve. The central part is made up of the ___ nuclei and all three destinations
Vertigo is involved with the vestibular nerve.
Vertigo gives the illusion of:
- Whirling
- Tilting
- Moving
- Spinning
The vestibular nerve is paried with the cochlear nerve to form the vestibulocochlear nerve. They then relay all the info to the vestibular nuclei in the brain stem. From the nuclei, there are three destinations:
- Floculonodular lobe of the cerebellum - receives info from the vestibular nuclei and helps with coordination of eye and head movements together.
- Abducens and oculomotor nerves - help with movement of eyes
- Vestibulospinal system (tract) - a descending white matter tract which talks to the reflex system of the body which helps keep the body keep up with the head.
The peripheral system is made up of the vestibular apparatus and vestibular nerve. The central part is made up of the vestibular nuclei and all three destinations
When we evaluate patients that have spinning or vertigo, there are two important things we want to ask patients:
1. ___-__\_
- ___ (how quickly did it begin? Was it acute or chronic in onset?)
- ____ over time (did it come on and stay there, or did it occur in episodes?)
2. ____/____ ____\_
- Is there a ___ that makes it better or worse?
When we evaluate patients that have spinning or vertigo, there are two important things we want to ask patients:
1. Time Course
-
-Onset (how quickly did it begin? Was it acute or chronic in onset?)
- Progression over time (did it come on and stay there, or did it occur in episodes?)
2. Aggravating/Alleviating Factors
- Is there a position that makes it better or worse?
Vertigo can manifest in three ways:
- ___
- __ __
- __ __, ___
1. __\_
- Chronic progressive vertigo
- Think mass ___ in the posterior fossa (i.e. __)
- Or mass lesion on vestibular system (i.e. vest. ___)
- Can also be ___ related
- Can also be psychiatric
2. __ __\_
- ___ ___ Syndrome
- Acute onset of prolonged ___ (will last for days)
- Symptoms are persistent and NOT ___
- Potential causes include:
- PERIPHERAL problems: vestibular ___, ___
- ____ problems: brainstem stroke
3. Acute Episodic & Recurrant
A. __\_
B. ___\_
A. ___:
- Provoked by sudden changes in head positions –> ___
- This can be tested by the ___-___ test
- This is caused by dislodged ___
- ___ (torsion of the eye/beating of eye)
B. ___\_
- ___ migraine
- causes headaches, dizziness, occurs in ____, and may or may not be associated with __ __
Vertigo can manifest in three ways:
- Chronic
- Acute Persistant
- Acute Episodice/Recurrant
1. Chronic
- Chronic progressive vertigo
- Think of a mass lesion in the posterior fossa (i.e. tumor)
- Or mass lesion on vestibular system (i.e. vest. schwanoma)
- Can also be medication related
- Can also be psychiatric
2. Acute Persistant
- Acute Vestibular Syndrome
- Acute onset of prolonged vertigo (will last for days)
- Symptoms are persistent and NOT episodic
- Potential causes include:
- PERIPHERAL problems: vestibular neuritis, labrynthitis
- CENTRAL problems: brainstem stroke
3. Acute Episodic & Recurrant
A. Positional
B. Sponaneous
A. Positional
- Provoked by sudden changes in head positions –> BPPV
- This can be tested by the Dix-Hallpike test
- This is caused by dislodged otoconia
- Nystagmus (torsion of the eye/beating of eye)
B. Spontaneous
- vestibular migraine
- causes headaches, dizziness, occurs in episodes, and may or may not be associated with head pain
Acute Vestibular Syndrome:
Dizziness or vertigo that develops ___ (__ to __)
- Associated with nausea, vomiting, gait instability, nystagmus, head-motion intolerance
- Often persists for a day or more
- Results from dysfunction of the ___ or ___ __ pathway
Causes:
_•Periphera_l (P-AVS)
- Vestibular ____: self-limited viral or post-viral syndrome
- AKA: ___thitis, ___hitis, acute peripheral ___
•Central (C-AVS)
- ___ stroke
- ___ stroke
- Others: ___ ___
Acute Vestibular Syndrome:
Dizziness or vertigo that develops acutely (seconds to hours)
- Associated with nausea, vomiting, gait instability, nystagmus, head-motion intolerance
- Often persists for a day or more
- Results from dysfunction of the peripheral or central vestibular pathway
Causes:
_•Periphera_l (P-AVS)
- Vestibular neuritis : self-limited viral or post-viral syndrome
- AKA: labrynthitis, neurolabrynthitis, acute peripheral vestibulopathy
•Central (C-AVS)
- Brain stem stroke
- Cerebellar stroke
- Others: MS
How can you tell the difference between a central and peripheral AVS?
HINTS of stroke
1.___ ___ Test
- Rapid and passive ___ head rotation from center to lateral position with patient ___ at central target
- Normal: eyes remain ___ to target
- Abnormal: ___ ___
2.___ (beating of eye)
•Repetitive, uncontrolled movements or shaking/jerking of the eyes
- Unidirectional:
- Indicates ____ pathology
- Often follows Alexander’s law (worse in the direction of the ___ phase) - they will always beat to left.
2.Direction changing:
- Indicates ___ pathology
- Refers to the direction of the __ phase
3.Test of _\_
- When one eye is above the other one. They are not on the same plane
- Subtle ___ -___ of the eyes
- Provoked by ___ cover test
- Normal: no __ deviation
- Abnormal: presence of __ deviation
How can you tell the difference between a central and peripheral AVS?
HINTS of stroke
1. Head Impulse Test
- Rapid and passive horiztonal head rotation from center to lateral position with patient fixated at central target
- Normal: eyes remain fixed to target
- Abnormal: corrective saccade
2. Nystagmus (beating of eye)
•Repetitive, uncontrolled movements or shaking/jerking of the eyes
- Unidirectional:
- Indicates peripheral pathology
- Often follows Alexander’s law (worse in the direction of the fast phase).
2.Direction changing:
- Indicates central pathology
- Refers to the direction of the fast phase
3.Test of Skew
- When one eye is above the other one. They are not on the same plane
- Subtle dis-conjugation of the eyes
- Provoked by alternate cover test
- Normal: no skew deviation
- Abnormal: presence of skew deviation
Hints of INFARCT
•INFARCT
____
_____ ___ ____
___ on ___ test
Hints of INFARCT
•INFARCT
Impulse test is Negative (does not show us correctiveness saccade)
Fast-phase Alternating
Refixation on Cover test
A corrective saccade indicates a positive test and the general practitioners can confidently make a diagnosis of vestibular as opposed to brainstem disease
Saccade - vestibular issue (peripheral)
No saccade - brainstem disease
