Vertigo and Syncope Flashcards
What is vertigo?
Sensation of movement when there is none or just abnormal movement, often spinning (tumbling, falling forward/back)
It is a symptom!
Associated with nystagmus and postural instability
What is disequilibrium?
Sense of imbalance (losing balance without sensation of movement)
-Imbalance and gait difficulties
What is presyncope?
Feeling of impending faint of LOC (no true syncope, generally associated with cardiac etiology)
Causes of vertigo
Peripheral (vestibular ex otologic lesion)
Central (central ex brainstem lesion)
Presentation of peripheral vertigo
Sudden, acute onset (may be severe)
Associated ear sxs (hearing loss, tinnitus)
Nystagmus can be horizontal and/or torsional (rotary)
Neuro sxs ABSENT
Presentation of central vertigo
May be gradual and progressive
Rare to have ear sxs
Nystagmus can occur in any direction, can be dissociated in 2 eyes (often vertical and nonfatigable)
Neuro sxs PRESENT (diplopia, ataxia, dysrthria)
May see HA or n/v
Lightheadedness
Vague, nonspecific “dizziness”
Can be associated with psych disorders (anxiety, depression, stress rxn) and hyperventilation
What to ask with the dizzy pt?
Duration of sxs and events
Relation to position (standing. head movement etc)
Possible triggers
Associated sxs (n/v, hearing loss, ear fullness, tinnitus, HA, vision, seizures, weakness)
What serious causes of vertigo MUST always be ruled out?
Cerebrovascular disease (vertebrobasilar insufficiency/stroke)
MS
Acoustic neuroma
Important parts of PE in vertigo
VS (orthostasis)
Ear (obstruction, fluid, perf)
Cardiac
Neuro (CNs, motor, cerebellar testing)
What is nystagmus?
Slow drift in one direction followed by fast response in the opposite direction
Categories of nystagmus
(direction of fast component)
Horizontal: peripheral or metabolic cause
Horizontal/torsional: peripheral or positional
Vertical: think CNS!!!
What is Dix-Hallpike maneuver most helpful for?
BPPV
What is electronystagmography or videonystagmography?
Assessment of vestibular function/ocular motility
-Record eye movements in response to visual, positional or rotational stimuli
What is caloric testing used for?
Vestibulo-ocular reflex
Normal response in caloric testing
COWS (Cold Opposite Warm Same)-direction of fast bearing nystagmus response
Cold water: eyes deviate ipsilateral and nystagmus beats away to opposite side
Warm water: eyes deviate contralateral and nystagmus beats to same side
What is vestibular paresis?
Seen in abnormal caloric testing
Impaired or absent thermally induced fast nystagmus (indicates pathology in labyrinth on irrigated side)
Most common cause of vertigo
Benign Paroxysmal Positional Vertigo
Presentation of BPPV
Transient (<1 min) episodes of vertigo associated with changes in head position
No hearing changes
Self limited but may last weeks or months
What is BPPV associated with?
Prolonged bed rest and head trauma
PE for BPPV
Normal
Dix-Hallpike can reproduce vertigo and horizontal nystagmus
Sxs fatigue with repetition
Management of BPPV
Reassurance that self-limited
Particle repositioning maneuvers
Vestibular rehab (OT or positional exercises)
Anti vertigo meds might help
First line vestibular suppressants
Anticholinergics (Scopolamine) or antihistamines (Meclizine or dimenhydrinate)
Other vestibular suppressants
Phenothiazines (prochlorperazine, promethazine)
Benzos
Etiology of vestibular neuritis
(vestibular neruonitis, labyrinthitis etc)
Young to middle age
Presumed viral or postviral inflammatory (affecting vestibular portion of CN VIII)
Presentation of vestibular neuritis
Single attack of severe vertigo (several days to a week)
Associated with viral URI
N/v and gait instability
No tinnitus or hearing loss (if hearing loss then labyrinthitis)
Fall to affected side
How to diagnose vestibular neuritis
Positive head thrust test
No CNS deficits
Audiograms normal
Caloric testing shows vestibular paresis on affected side
Management of vestibular neuritis
Self-limited Symptomatic tx (bed rest, vestibular suppressants, anti-emetics PRN, prednisone taper over 10 days)
Pathogenesis of Meniere’s
Secondary to endolympathic hydrops (syphilis and head trauma)-distortion of membranous endolymph containing portions of labyrinthine system
Rupture theory of Meniere’s
Swelling then rupture of membranous labyrinth causes paralysis of vestibular nerve fibers and degeneration of cochlear hair cells
Presentation of Meniere’s
Triad: episodic vertigo, tinnitus and fluctuating hearing loss
Sudden onset of attacks (20 min-24 hrs)
Fullness of ear, n/v
Progression of Meniere’s
Hearing loss gets worse and can eventually be irreversible
Audiogram will show sensorineural hearing loss
Lose low tones and then high tones
When do attacks of vertigo stop with Meniere’s?
When deafness is complete
Management of acute attack of Meniere’s
Bed rest
Symptomatic: anti-emetics or vestibular suppressants
Prophylactic management of Meniere’s
Low salt diets
Limit caffeine, nicotine, alcohol, MSG
Diuretics (HCTZ)
Surgical management for refractory Meniere’s
Intratympanic corticosteroid injection Endolymphatic sac decompression Vestibular ablation (transtympanic gentamicin, vestibular nerve section, surgical labyrinthectomy)
What is a perilymphatic fistula?
Abnormal connection between perilymph and middle ear (inner ear fluid can leak into middle ear)
Presentation of perilymphatic fistula
Associated with sudden changes in pressure of middle ear (head trauma, weight lifting, erosion, congenital)
Hearing loss, tinnitus, vertigo
How to confirm presence of perilymphatic fistula
Pneumatic otoscope (abnormal to see eye movements with changes in pressure but may see nystagmus)
Management of perilymphatic fistula
Bedrest
Hydration
Symptomatic
Surgery
Red flags with vertigo
Neuro deficit
Ipsilateral hearing loss
Gait abnormality
Direction changing nystagmus
Sxs leading to a diagnosis of vertigo: aural fullness
Acoustic neuroma
Menieres
Sxs leading to a diagnosis of vertigo: ear/mastoid pain
Acoustic neuroma
Acute middle ear disease (AOM, herpes zoster oticus)
Sxs leading to a diagnosis of vertigo: facial weakness
Acoustic neuroma
Herpes zoster oticus
Sxs leading to a diagnosis of vertigo: focal neuro findings
Cerebellar tumor
CVD
MS
Sxs leading to a diagnosis of vertigo: HA
Acoustic neuroma
Migraine
Sxs leading to a diagnosis of vertigo: hearing loss
Menieres Acoustic neuroma Otosclerosis Labyrinthitis Herpes zoster TIA Cholesteatoma Perilympathic fistula
Sxs leading to a diagnosis of vertigo: imbalance
Acute vestibular neuritis (moderate) Cerebellar tumor (severe)
Sxs leading to a diagnosis of vertigo: phono/photophobia
Migraine
Sxs leading to a diagnosis of vertigo: rash
Herpes zoster oticus
Sxs leading to a diagnosis of vertigo: tinnitus
Acute labyrinthitis
Acoustic neuroma
Menieres
Provoking factors leading to a diagnosis of vertigo: changes in head position
Acute labyrinthitis BPPV Cerebellar tumor MS Perilymphatic fistula
Provoking factors leading to a diagnosis of vertigo: spontaneous with no provoking factors
Vestibular neuritis TIA/CVA Menieres Migraine MS
Provoking factors leading to a diagnosis of vertigo: recent URI
Vestibular neuritis
Provoking factors leading to a diagnosis of vertigo: stress
Psychogenic
Migraine
Provoking factors leading to a diagnosis of vertigo: immunosuppresion
Herpes zoster oticus
Provoking factors leading to a diagnosis of vertigo: changes in ear pressure, trauma, noises
Perilymphatic fistula
What is syncope?
Sudden, transient loss of consciousness with spontaneous recovery (loss of postural tone, due to diminished cerebral BF)
Possible etiologies of syncope
Neurally mediated/neurocardiogenic-reflex syncope
Cardiac (higher risk of death)- obstruction, arrhythmias
Orthostatic/autonomic
Psych (GAD, panic attacks, somatic sx disorder)
Prodrome associated with syncope
Uneasiness or apprehension
Lightheaded, facial pallor, diaphoresis, nausea
Visual blurring, CP, SOB, HA, neuro sxs
What part of the prodrome is consistent with vasovagal syncope?
Lightheaded, facial pallor, diaphoresis, nausea
BP positive for orthostasis
Drop in systolic >20 or diastolic >10
Diagnostics for syncope
EKC Echo (when cardiac disease, abnormal PE or ECG) Electrophysiologic testing Exercise stress testing maybe Carotid u/s Neuroimaging MRI if abnormal PE EEG r/o seizure Labs
When is tilt table indicated?
For recurrent episodes of unexplained syncope and no history of cardiac disease
What is the tilt table?
Provocative test for vasovagal syncope
Pt is tilted upright by 60-90 degrees:
Normal is minimal drop in BP and increase HR
Abnormal is exaggerated drop in BP with or without drop in HR associated with dizzy or lightheaded
When is carotid sinus massage indicated?
Recurrent episodes of syncope with negative work up or history of carotid sinus syncope
What is the carotid sinus massage?
Massage it for 5-10 sec and monitor HR and BP
(palpate carotids and listen for bruit first!)
+ is sxs reproduced and period of asystole >3-5 sec or drop in BP (>50 mmHg)
Contraindications for carotid sinus massage
Prior TIA or stroke within last 3 mos
Pts with carotid bruits
Risk factors for cardiac syncope
Abnormal EKG History of ventricular arrhythmias History of HF Age >45 *poor prognosis so need to ID (palpitations associated suggest hypotension and mad arrhythmia)
Bradyarrhythmia in cardiac syncope
Sinus node dysfunction AV block (Second degree type II or complete)
Tacharrhythmias in cardiac syncope
SVT
Wolff Parkinson White
Ventricular tachycardia
Do ECG and Holter
Most common outflow obstruction leading to cardiac syncope
Aortic stenosis
Presentation of cardiac syncope from aortic stenosis
Exertion association and cannot compensate
Cardiac syncope due to aortic dissection
Acute onset of tearing pain radiating to back
Unstable pt means high mortality
How to distinguish HCM from cardiac syncope
See dyspnea and increased systolic heart murmur with standing or exertion
How to distinguish PE from cardiac syncope
Acute dyspnea, pleuritic chest pain, hemopytysis and leg swelling
How to distinguish cardiac tamponade from syncope
Muffled hearts sounds and increased neck veins
What is reflex syncope?
Loss of sympathetic tone (or sudden increase in parasympathetic) leading to vasodilation and bradycardia and then hypotension and syncope
Vasovagal, carotid sinus, situational
Vasovagal syncope
Seen in adolescents and YAs
Emotional lability and stress, usually a provoking stimulus
Prodrome of diaphoresis, nausea and pallor
No long term tx needed
Who has carotid sinus syncope?
Middle age or elderly (probs male with atherosclerotic vascular disease)
Tight collars or shaving can precipitate
Tx for carotid sinus syncope
Cardiac pacemaker
What is micturition syncope?
Syncopal episode after emptying distended bladder
Seen after excess fluid ingestion, maybe alcohol
Secondary to vagal stimulation or orthostasis
What is tussive syncope?
Seen in barrel chest/COPD/ kids with asthma
Severe coughing increases intrathoracic pressure and decreases CO
Causes of orthostatic hypotension
Autonomic failure
Vol depletion
Aging
Meds (anti-hypertensives, TCAs)
Associations of orthostatic hypotensions
Diabetic polyneuropathy, PD
Malnutrition, anemia, blood loss, adrenal insufficiency all worsen it
Management of orthostatic hypotension
Avoid vol depletion
Med adjustment
Behavior (slow movements, doriflex feet or handgrip before standing, jobst stocking)
What is subclavian steal syndrome?
Stenosis of subclavian artery near origin and flow reversal in ipsilateral vertebral artery causing decreased brain perfusion
Sxs of subclavian steal syndrome
Diplopia, vertigo, syncope, dysrthria, ataxia
Look for sxs with arm exertion
look for different UE pulses
Management of syncope
Treat underlying disorder
IF remains unexplained then probably benign with good prognosis
