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Project - USMLE Step 3 > Symptom To Diagnosis - Dizziness > Flashcards

Symptom To Diagnosis - Dizziness Flashcards

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USMLE® Step 1 flashcards
1
Q

Vertigo - Chief complaint:

A

Spinning.

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2
Q

Near syncope - Chief complaint:

A

Nearly fainting.

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3
Q

Dysequilibrium - Chief complaint:

A

Falling, loss of balance.

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4
Q

Non specific dizziness - Chief complaint:

A

Floating vague.

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5
Q

Vertigo - Typical precipitants:

A

Turning over in bed.

Looking up to shelf.

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6
Q

Near syncope - Typical precipitant:

A

Standing.

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7
Q

Dysequilibrium - Typical precipitant:

A

Walking.

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8
Q

Non specific dizziness - Typical precipitant:

A

Stress.

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9
Q

Vertigo - Important historical clues:

A

Attack duration.
CNS signs or symptoms (dysarthria, ataxia, diplopia, headache, neck pain).
Peripheral symptoms –> Hearing loss, tinnitus.

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10
Q

Near syncope - Important historical clues:

A
  1. CAD HF.
  2. History of syncope.
  3. Palpitations.
  4. Medications.
  5. Melena or rectal bleeding.
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11
Q

Dysequilibrium - Improtant historical clues:

A
  1. Diabetes.
  2. Neuropathy.
  3. Visual problems.
  4. Imbalance.
  5. Medications.
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12
Q

Non specific dizziness - Important historical clues:

A
  1. Multiple somatic complaints.
  2. Feeling down or hopeless.
  3. Anhedonia.
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13
Q

Vertigo - Key exam physical findings:

A
  1. Cranial nerve exam.
  2. Gait.
  3. Finger-to-nose exam.
  4. Dix-Hallpike maneuver.
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14
Q

Near syncope - Key physical exam findings:

A
  1. Orthostatic blood pressure and pulse.

2. Cardiac exam.

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15
Q

Dysequilibrium - Key physical exam findings:

A
  1. Gait.
  2. Sensation.
  3. Position sense.
  4. Cranial nerve exam.
  5. Finger to nose exam.
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16
Q

Vertigo - DDX:

A

PERIPHERAL –> BPPV, vestibular neuritis, Meniere.

CENTRAL –> CVA, MS, Cerebellar hemorrhage, migraine, Brainstem Tumors.

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17
Q

Near syncope - DDX:

A
  1. Dehydration.
  2. Hemorrhage.
  3. Orthostatic hypotension.
  4. Vasovagal reflexes.
  5. Arrhythmias.
  6. Hypoglycemia.
  7. Aortic stenosis.
  8. PE.
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18
Q

Dysequilibrium - DDX:

A
  1. Multiple sensory deficits.
  2. Parkinson disease.
  3. Cerebellar degeneration or stoke.
  4. B12 def.
  5. Tabes dorsalis.
  6. Myelopathy.
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19
Q

Non specific dizziness - DDX:

A
  1. Depression.
  2. Generalized anxiety disorder.
  3. Panic attacks.
  4. Somatization disorder.
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20
Q

MCC of dizziness:

A

Vertigo.

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21
Q

About …% of vertigo patients have peripheral etiology.

A

90%.

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22
Q

Peripheral vertigo:

A
  1. BPPV.
  2. Labyrinthitis or vestibular neuritis.
  3. Meniere.
  4. Uncommon –> Head trauma, herpes zoster.
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23
Q

Central vertigo:

A
  1. CVA.
  2. Cerebellar degeneration.
  3. Migraine.
  4. MS.
  5. Alcohol intoxication.
  6. Phenytoin toxicity.
  7. Tumors of the BRAINSTEM or cerebellum.
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24
Q

Central vertigo - CVA:

A
  1. Vertebral insufficiency.
  2. Cerebellar or Brainstem stroke.
  3. Cerebellar hemorrhage.
  4. Vertebral artery dissection.
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25
Q

Near syncope is a common cause of dizziness particularly in the …?

A

Elderly.

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26
Q

Dysequilibrium - Etiologies:

A
  1. Multiple sensory deficits.
  2. Parkinson disease.
  3. Normal-pressure hydrocephalus.
  4. Cerebellar disease (degeneration, tumor, infarction).
  5. Peripheral neuropathy (diabetes).
  6. Dorsal column lesions (B12, syphilis, compressive lesions).
  7. Drugs.
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27
Q

Drugs that may cause dysequilibrium:

A
  1. Alcohol.
  2. Benzodiazepines.
  3. Anticonvulsants.
  4. Aminoglycosides.
  5. Antihypertensives.
  6. Muscle relaxants.
  7. Cisplatin.
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28
Q

Non specific dizziness - Etiologies:

A
  1. Psychological –> Major depression, anxiety, panic disorders, somatization disorders.
  2. Recently corrected vision –> New glasses, Cataract removal.
  3. Medication side effect.
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29
Q

Features suggesting CENTRAL vertigo?

A
  1. CNS signs.
  2. CNS symptoms.
  3. Severe headache or neck pain.
  4. Significant imbalance.
  5. CEREBROVASCULAR risk factors.
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30
Q

BPPV - Textbook presentation:

A

Abrupt onset of severe dizziness –> The room is spinning.

  • -> They often describe it as feeling like the room is spinning.
  • -> They often note that the symptoms began when they rolled over in bed, looked up (to get something out of the closet), or bend down to tie their shoes.
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31
Q

BPPV - Duration of symptoms:

A

Each episode is brief (10-20 sec) rather than persistent (as in vestibular neuritis).
However, since the episodes occur in clusters, patients often complain of vertigo that occurs for days to weeks.

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32
Q

BPPV - Vertigo precipitated by?

A

Positional changes.

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33
Q

BPPV is 2o to?

A

Free-floating canalith usually within posterior semicircular canal.
–> Precipitant is usually unknown, although BPPV may follow labyrinthitis or head trauma.

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34
Q

EBD of BPPV - Criteria:

A
  1. Recurrent vertigo.
  2. Duration of attack <1min.
  3. Symptoms invariably provoked by changing head position.
  4. Not attributable to another disorder.
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35
Q

BPPV criteria - Symptoms provoked by changing head position?

A
  1. Lying down or turning over in bed or

2. 2 of the following: Reclining the head, rising from supine, or bending forward.

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36
Q

EBD of BPPV - Patients with all 4 criteria?

A

Sens - 88%.
Spec - 92%.
LR+ 11.
LR- 0.13.

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37
Q

One study reported that ALL patients with BPPV complained that the vertigo was?

A

Provoked by turning over in bed.

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38
Q

EBD of BPPV - …% complained of imbalance, but falling was rare (…/…) and should raise the concern of another disorder.

A

50%.

1/61.

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39
Q

What type of nystagmus does BPPV have and how is it precipitated?

A
  1. Nystagmus usually begins after a few seconds, is brief (<30sec), and fatigues with repetition of maneuver.
  2. Sens 42-78%.
  3. Spec 94%.
  4. Nystagmus that begins immediately, lasts longer than 1 minute or fails to fatigue suggests a central (brainstem) disorder.
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40
Q

EBD of BPPV - When to perform CNS imaging?

A

CNS imaging should be performed in patients with findings that suggest central disease and in patients with atypical findings for BPPV.

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41
Q

Acute vestibular neuritis - Textbook presentation:

A

Typically presents ABRUPTLY with severe CONSTANT vertigo and nausea made worse by head turning that lasts for days.
–> Subsequently, patients may complain of INTERMITTENT vertigo that occurs for weeks to months and is precipitated by head movement.

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42
Q

Acute vestibular neuritis may follow?

A

Viral infection involving the vestibular nerve and the labyrinth.

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43
Q

Acute vestibular neuritis - Nystagmus:

A

Patients often have spontaneous vestibular nystagmus that is unilateral, horizontal, or horizontal and torsional and suppressed by visual fixation.

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44
Q

Acute vestibular neuritis - Nausea and vomiting are?

A

Common.

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45
Q

Acute vestibular neuritis - How long does the vertigo last?

A

2-3 days. May last up to 1 week.

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46
Q

Ramsay-Hunt syndrome?

A

Variant of vestibular neuritis.

  • -> VZV reactivation involving cranial nerves VII and VIII produces vestibular neuritis with hearing loss and facial weakness.
  • -> VESICLES are seen in the external auditory canal.
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47
Q

EBD - Acute vestibular neuritis:

A
  1. Clinical diagnosis.

2. Cerebellar infarction may present like vestibular neuritis and needs to be carefully considered.

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48
Q

EBD of Acute vestibular neuritis - When to perform an MRI?

A
  1. Headache.
  2. Weakness.
  3. Dysmetria.
  4. Inability to ambulate.
  5. Cranial nerve findings.
  6. Skew deviation.
  7. Nystagmus which is not suppressed by visual fixation.
  8. Risk factors for vascular disease.
  9. Persistence of severe vertigo beyond a few days.
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49
Q

Meniere disease - Textbook presentation:

A

Patients complain of INTERMITTENT vertigo. They may note ear fullness, unilateral hearing loss, and tinnitus.
Spells typically last for minutes to hours (rarely longer than 4-5 hours) and occasionally up to a day.

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50
Q

Meniere disease - Disease highlight:

A

Excess fluid in the endolymphatic spaces of the inner ear.

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51
Q

EBD of Meniere - Diagnostic criteria:

A

Requires the following for a definite diagnosis:

  1. Two spontaneous episodes of vertigo lasting >20min.
  2. Confirmed sensorineural hearing loss.
  3. Tinnitus or perception of aural fullness, of both.
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52
Q

EBD of Meniere - Rule out syphilis:

A

Test should be done to rule out syphilis (FTA-Ab).

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53
Q

Migraine - Textbook presentation:

A

Sufferers complain of intermittent attacks of severe unilateral throbbing headache associated with:

  1. Photophobia.
  2. Phonophobia.
  3. Nausea.
  4. Vomiting.
    - -> Headaches may be preceded by a visual aura (scotoma or scintillating lights).
    - -> Occasionally: Vertigo.
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54
Q

Suggested criteria for migrainous vertigo:

A
  1. Recurrent episodic vertigo.
  2. Current or prior history of migraine.
  3. One of the following symptoms during at least 2 vertiginous attacks:
    - -> Migrainous headache.
    - -> Photophobia.
    - -> Phonophobia.
    - -> Visual or other auras.
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55
Q

Migrainous vertigo - Duration:

A

May last several hours or days and may be spontaneous or positional.

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56
Q

EBD of migrainous vertigo - Sequence of events:

A

In patients with vertigo due to migraine, vertigo may precede, be concurrent with, or temporally unrelated to headache.

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57
Q

EBD of migrainous vertigo - Correlation of vertigo and headache:

A

45% –> Vertigo regularly associated with headache.
48% –> Vertigo occurs with AND without headache.
6% –> Vertigo and migraine did NOT occur together.

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58
Q

Cerebellar hemorrhage - Textbook presentation:

A

ABRUPT onset of headache associated with vomiting, ataxia, and vertigo.

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59
Q

Cerebellar hemorrhage - Occurs with?

A

Exertion or at rest.

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60
Q

Cerebellar hemorrhage accounts for …-…% cases of intracerebral hemorrhages.

A

5-16%.

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61
Q

Cerebellar hemorrhage - Etiology - Common etiologies:

A
  1. Hypertensive hemorrhage.
  2. Subarachnoid hemorrhage.
  3. Amyloid angiopathy.
  4. AV malformations.
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62
Q

Cerebellar hemorrhage - Less common etiologies:

A
  1. Blood dyscrasias.
  2. Hemorrhagic infarction.
  3. Septic emboli.
  4. Anticoagulant and Thrombolytic therapy.
  5. Neoplasms.
  6. HSV encephalitis.
  7. Cocaine and amphetamine use.
63
Q

Cerebellar hemorrhage - Demographics - Mean age and race

A

61-73.

Asians > Blacks > Hispanics > Whites.

64
Q

Cerebellar hemorrhage - DM?

A

36%.

65
Q

Cerebellar hemorrhage - Hypertension?

A

32-73%.

66
Q

Cerebellar hemorrhage - Coagulation disorders:

A

14%.

67
Q

Cerebellar hemorrhage - Liver disease:

A

16%.

68
Q

Cerebellar hemorrhage - Initial symptom:

A

Headache in 80%.

69
Q

Cerebellar hemorrhage must be considered in patients?

A

Who complain of acute headache + Vertigo.

70
Q

Cerebellar hemorrhage presentation - …% of patients are comatose at presentation.

A

60%.

71
Q

Cerebellar hemorrhage presentation - …% of patients demonstrate an increase in the hematoma on repeat CT scan 3 hours after the initial scan.

A

38%.

72
Q

Cerebellar hemorrhage complications:

A

48% –> Hydrocephalus.
Chronic disability.
42% –> Herniation.
Pneumonia, AMI, ventricular arrhythmias.

73
Q

Cerebellar hemorrhage - Poor prognostic factors:

A
  1. Marked hydrocephalus.
  2. Deteriorating consciousness.
  3. Stupor and coma (100% mortality without surgery).
  4. Fever –> Correlates with ventricular extension of bleeding.
74
Q

EBD of cerebellar hemorrhage - Brainstem findings are common?

A

Yes, 100% in one study.

75
Q

EBD of Cerebellar hemorrhage - Lab evaluations should include:

A
  1. CBC.
  2. Platelet count.
  3. INR.
  4. PTT.
  5. Basic metabolic panel.
  6. ECG.
  7. CXR.
  8. Glucose.
  9. Tox screen in young and middle aged patients.
76
Q

EBD of Cerebellar hemorrhage - Cross sectional imaging is critical - Tests of choice are:

A

Non contrast CT and MRI/MRA.

77
Q

Vertebral artery dissection - Textbook presentation:

A

Unlike patients with atherosclerotic disease, patients with VAD are usually younger (mean age 48) and complain of severe neck pain, occipital headache, and evolving neurologic symptoms due to progressive involvement of the brainstem.

78
Q

Vertebral artery dissection - Possible complications:

A
  1. Numbness.
  2. Hemiparesis.
  3. Quadriparesis.
  4. Coma.
  5. Locked-in syndrome.
  6. Death.
79
Q

Risk factors for vertebral artery dissection?

A

Differ from patients with typical ischemic stroke.

  1. May occur spontaneously.
  2. Following trauma.
  3. Catheterization.
  4. Sporting activity.
  5. Chiropractic cervical manipulation.
80
Q

EBD of vertebral artery dissection - Warning symptoms:

A

Present in 54%.

  1. MC are occipital headache and neck pain.
  2. These symptoms are usually SUDDEN, severe, and persistent until other neurologic signs develop.
  3. Headache preceded other neurologic signs and symptoms by 1-14 days.
81
Q

EBD of vertebral artery dissection - Signs and symptoms - Pain?

A

In 85% of cases.

82
Q

EBD of VAD - Other symptoms:

A 
57% --> Vertigo.
53% --> Nausea/vomiting.
46% --> Unilateral facial numbness.
42% --> Unsteadiness.
35% --> Cerebellar findings.
23% --> Diplopia.
11% --> Limb weakness.
83
Q

EBD of VAD - Isolated vertigo and headache:

A

12%.

84
Q

EBD of VAD - Imaging?

A
  1. MRA.
  2. CTA.
  3. Conventional angiography.
85
Q

EBD of VAD - Neuroimaging:

A

65% –> Infarction.

86
Q

MS - Textbook presentation:

A

MS typically affects young women of Northern European dissent who experience intermittent Neurologic symptoms due to disease that develops at DIFFERENT times and at DIFFERENT locations in the CNS.

87
Q

MC presenting form of MS is …?

A

Relapsing-remitting MS, characterized by attacks followed by REMISSION and REMYELINATION.
58% –> This form of disease transforms into secondary progressive MS.

88
Q

Symptoms of MS worsen in …?

A

Warm environments (ie in the shower).

89
Q

Role of EBV in MS:

A

Several studies suggest that late infection with EBV (ie in the adolescence) may predispose to MS.

90
Q

Although MS evolves with time into a Multifocal disease, …% of patients present with one or of several clinically isolated syndromes (CIS).

A

85%.

91
Q

Common CIS in MS include?

A
  1. Partial spinal cord syndromes.
  2. Optic neuritis.
  3. Intranuclear ophthalmoplegia (INO).
92
Q

Partial spinal cord syndrome - Features:

A
  1. Band-like sensation.
  2. Varying degrees of pain, light touch, and proprioceptive loss.
  3. Bilateral sensory loss from a certain level downwards.
  4. Weakness associated with spasticity, hyperreflexia, and clonus.
  5. Electrical sensation from spine into the limbs that occurs with neck flexion (Lhermitte sign).
93
Q

Optic neuritis is the presenting complaint in …-…% of patients in whom MS is subsequently diagnosed.

A

15-20%.

94
Q

Optic neuritis - For what do patients complain?

A
  1. Monocular visual loss.
  2. Monocular visual field loss (scotoma).
  3. Difficulty discerning color that evolves over hours to days.
95
Q

Optic neuritis - Pain?

A

92% –> Pain with extraocular movement is common.

96
Q

Optic neuritis - Marcus Gunn pupil:

A

Almost always seen –> AFFERENT pupillary defect.

97
Q

With long term follow-up, MS develops in up to …-…% of patients with optic neuritis.

A

15-75%.

98
Q

Intranuclear ophthalmoplegia - What happens:

A
  1. Medial longitudinal fasciculus pathway in the brainstem coordinates conjugate eye movement.
  2. An INO develops when a lesion interrupts this pathway.
99
Q

Sign of INO:

A

On lateral gaze, Adduction is impaired and nystagmus develops in the abducting eye.

100
Q

How do we distinguish an INO from a 3rd nerve palsy?

A

Convergence is maintained.

101
Q

INO is seen in …-…% of MS patients.

A

33-50%.

102
Q

Is INO specific for MS?

A

No, it may develop secondary to vascular disease.

103
Q

Vertigo is the presenting symptom in …% of MS.

A

5%.

104
Q

Vertigo is reported in …-…% of patients with MS.

A

30-50%.

105
Q

MS - Other common presenting symptoms:

A
  1. Variety of sensory symptoms.
  2. Urinary incontinence.
  3. Heat sensitivity.
  4. Fatigue.
  5. Depression.
  6. Cognitive dysfunction.
106
Q

MS - Prognosis at 10 years.

A

50% of patients require a cane.

15% of patients are wheelchair-dependent.

107
Q

EBD of MS - test of choice:

A

Brain MRI.

108
Q

Brain MRI demonstrates what in MS?

A

Periventricular white matter lesions (lesions may also be seen in other white matter locations).

109
Q

Brain MRI in MS - Sens and spec?

A

Sens 81-90%.

Spec 71-96%.

110
Q

What may look similar to MS on Brain MRI?

A
  1. Ischemia.
  2. SLE.
  3. Behcet.
  4. Syphilis.
  5. HIV.
  6. Sarcoidosis.
111
Q

Spinal or Brain MRI?

A

Spinal MRI has similar sensitivity (75-83%) to Brain MRI but is more specific (97%) than Brain MRI.

112
Q

EBD of MS - Visual Evoked potentials:

A

Visual evoked potentials are sensitive but not specific for MS.

113
Q

EBD of MS: Somatosensory evoked potentials:

A

69-77% sensitive.

Abnormal in 50% of patients with MS without sensory signs or symptoms.

114
Q

EBD of MS - CSF analysis:

A

In patients in whom the diagnosis is uncertain.
1. Cell counts are usually normal.
2. Ig (Oligoclonal bands) may be elevated.
–> Elevated in 60-70% of patients with CIS and 85-95% of patients with MS –> 92% specific.
LR+ 11.3, LR- 0.11.

115
Q

EBD of MS - How many patients with oligoclonal bands progressed to MS?

A

25% of patients with oligoclonal bands and 1 event progressed to MS, compared with 9% without bands (at 3 years).

116
Q

EBD of MS - DDX:

A
  1. Acute disseminated encephalomyelitis.
  2. Transverse myelitis.
  3. CNS vasculitis.
  4. SLE.
  5. Syphilis.
  6. HIV.
  7. HTLV-1.
  8. Neurosarcoidosis.
  9. CVA.
  10. Antiphospholipid syndrome.
  11. Lyme.
    12 Migraine.
117
Q

EBD of MS - Clues to alternative etiology:

A
  1. Single CNS lesion.
  2. Unusual age of presentation.
  3. Spinal lesion in the absence of intracranial disease.
118
Q

Dysequilibrium can arise from abnormalities of?

A
  1. Brain.
  2. Cerebellum.
  3. Spinal cord.
  4. Peripheral nerves.
119
Q

Dysequilibrium etiology:

A
  1. Parkinson disease.
  2. Normal pressure hydrocephalus.
  3. Cerebellar degeneration (from alcohol).
  4. Cerebellar stroke.
  5. Vertebrobasilar insufficiency.
  6. B12 def.
  7. Tabes Dorsalis.
  8. Multiple sensory deficits.
  9. Drugs.
120
Q

Multiple sensory deficits - Textbook presentation:

A
  1. The typical patient is an elderly diabetic who complains of symptoms when arising from their bed during the night.
  2. Patients may fall or simply feel that they are going to fall.
  3. Multiple losses and physical deconditioning create imbalance and an unsteady gait.
  4. Orthostatic hypotension (aggravated by many medical conditions) and benzodiazepines for sleep may contribute to the symptoms.
121
Q

Multiple sensory deficits - Typically 2 or more of the following are present:

A
  1. Visual loss (2o to myopia, presbyopia, cataracts, macular degeneration).
  2. Proprioceptive loss (neuropathy from DM, myelopathy from cervical spondylosis).
  3. Chronic bilateral vestibular damage (from ototoxic drugs).
  4. Orthopedic disorder impairing ambulation.
122
Q

EBD of multiple sensory deficits:

A
  1. Ataxia is uncommon (0/14 in one series).

2. Patients with significant ataxia or Cerebellar findings should undergo MRI to exclude alternative diagnoses.

123
Q

Cerebrovascular disease - Etiology:

A
  1. Thrombosis.
  2. Embolization.
  3. Hemorrhage.
  4. Dissection of the carotid or vertebral arteries.
  5. Hypotension.
124
Q

EBD of cerebrovascular disease - Initial evaluation p:

A
  1. Serum glucose.
  2. CBC.
  3. PT.
  4. PTT.
  5. Basic metabolic panel.
  6. ECG –> Afib or MI.
  7. Neuroimaging.
125
Q

EBD of cerebrovascular disease - Neuroimaging:

A

MRI is far superior to CT scan for the diagnosis of ISCHEMIC stroke and almost identical for the diagnosis of hemorrhagic stroke.

126
Q

Vertebrobasilar insufficiency (VBI) - Textbook presentation:

A

Classic presentation is an elderly patients with diabetes, HTN, or both who complains of intermittent spells of vertigo associated with other neurologic symptoms, such as diplopia, dysphagia, weakness, or ataxia.

127
Q

VBI risk factors:

A
  1. Diabetes.
  2. HTN.
  3. Increased age.
  4. CAD.
  5. Peripheral vascular disease.
  6. Tobacco use.
  7. Male sex.
128
Q

VBI - Dizziness may be described as?

A

Tilting rather than spinning.

129
Q

VBI - Symptoms?

A

Usually lasts for minutes in patients with VBI but may persist in patients with stroke or Cerebellar hemorrhage.

130
Q

VBI - Basilar artery Infarctions may result in?

A
  1. Cranial neuropathies.
  2. Hemiparesis.
  3. Coma.
131
Q

EBD of VBI - …% of patients have a normal neurologic exam between the episodes.

A

50%.

132
Q

EBD of VBI - Other CNS symptoms?

A

In most patients with VBI and vertigo, other CNS symptoms or signs are also present.
HOWEVER –> 7.5-20% of VBI, intermittent vertigo presents as the sole manifestation of basilar ischemia, which can be a harbinger of flank brainstem infarction.

133
Q

Important point about basilar ischemia:

A

Should be considered in patients with vertigo that is NOT clearly positional and who have significant cerebrovascular disease risk factors (ie diabetes).

134
Q

MC symptom in VBI:

A

Visual dysfunction:

  1. Diplopia.
  2. Visual field defects.
  3. Hallucinations.
  4. Blindness.
135
Q

EBD of VBI - Imaging study of choice?

A

MRI with MRA is the procedure of choice:

  • -> Non invasive.
  • -> Sens 95-97%, Spec 99% for posterior circulation disorders.
136
Q

EBD of VBI - Imaging - When to avoid MRA?

A

PACEMAKERS –> DO A CTA.

137
Q

Gold standard in imaging of VBI:

A

Angiography, but invasive.

138
Q

Lacunar infarction of the Pons or Cerebellum - Textbook presentation.

A

Typically, presenting symptoms are rapid onset of hemiparesis, sensory symptoms, or ataxia.

139
Q

Lacunar infarction of the pons or cerebellum - Highlights:

A
  1. Small, deep, NON cortical, white matter infarcts 2o to obstruction of the small penetrating arteries.
  2. Typically involves basal ganglia, internal capsule, thalamus, and pons.
140
Q

Lacunar infarction of the pons or cerebellum - Cortical signs?

A

ABSENT - No aphasia, agnosia, apraxia, and hemianopsia.

–> Symptoms depend on stroke location.

141
Q

Etiology of Lacunar infarcts of Pons and cerebellum:

A
  1. Hyalinosis of the small penetrating artery with subsequent thrombosis is the MCC –> Long term complication of HTN.
  2. Thrombosis/embolization of small penetrating artery arising from MCA or basilar artery.
  3. Cardioembolism.
142
Q

Risk factors of Lacunar infarction of pons or cerebellum:

A
  1. HTN.
  2. Diabetes.
  3. Smoking.
143
Q

Lacunar infarction of the pons or cerebellum - Incidence:

A

Twice more common in blacks.

144
Q

Skew deviation suggests?

A

CEREBELLAR INFARCTION –> 100% specific, but not sensitive.

145
Q

The presence of ANY of the following features in a patient with persistent vertigo suggests that a patient may have cerebellar infarction and warrants an MRI/MRA:

A
  1. Headache.
  2. Weakness.
  3. Dysmetria.
  4. Inability to ambulate.
  5. Cranial nerve findings.
  6. Skew deviation.
  7. Nystagmus that is NOT suppressed by visual fixation.
  8. Risk factors for vascular disease.
146
Q

EBD of lacunar infarction of pons or cerebellum:

A 
CT --> Sens is low, 30-44%.
MRI --> Sens is 86%.
MRA --> To visualize/exclude occlusion of large feeding vessel. Useful in those without risk factors.
Echo --> Emboli.
ESR --> For vasculitides.
147
Q

Non specific dizziness - Textbook presentation:

A
  1. Psychiatric patients.
  2. Long duration and poorly defined dizziness.
  3. Patients may complain of other symptoms particularly if they have panic attacks.
148
Q

…-…% of patients attending a specialty dizzy clinic demonstrated panic disorder.

A

20-38%.

149
Q

Non specific dizziness - Highlights:

A
  1. Psychiatric symptoms may develop without any identifiable organic cause OR develop AFTER episodes of true vertigo or syncope.
  2. Symptoms are in part 2o to hyperventilation, which leads to hypocapnia, resulting in decreased cerebral blood flow.
  3. Patients may complain of light-headedness or near syncope.
150
Q

EBD of non specific dizziness - continuous vertigo of >1-2 weeks without daily variation is most likely to be…?

A

Psychogenic –> Distinguished from intermittent vertigo, recurring for weeks, precipitated by motion.

151
Q

EBD of non specific dizziness - One study reported that …% of patients with hyperventilation had other significant psychiatric disorders.

A

62%.

152
Q

EBD of non specific dizziness - Care must be taken before ascribing dizziness to a psychiatric etiology:

A

22-67% anxiety, among patients with well-defined organic etiologies of their dizziness.
–>Anxiety scores were as high in patients with acute labyrinthine failure and vestibular dysfunction as among patients with no vestibular diagnosis.
BOTTOM LINE –> Dizziness from an organic etiology leads to significant psychiatric distress in many patients and that the psychiatric symptoms may be sequelae of the dizziness rather than the cause of dizziness.

153
Q

EBD of non specific dizziness - Certain physical findings that suggest a psychogenic disturbance:

A
  1. Moment to moment fluctuations in impairment.
  2. Excessive slowness or hesitation.
  3. Exaggerated sway on Romberg, improved by distraction.
  4. Sudden buckling of knee, typically without falling.
  5. Cautious “walking on ice” pattern.
154
Q

Complaint of dizziness is actually what?

A

1 of 4 distinct sensations:

  1. Vertigo.
  2. Near syncope.
  3. Dysequilibrium.
  4. Non specific dizziness.

Project - USMLE Step 3 (82 decks)

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