Articles: vertigo.
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Comparative Study
The costs and utility of imaging in evaluating dizzy patients in the emergency room.
To determine the usefulness and the costs of computed tomography (CT) and magnetic resonance imaging (MRI) in the evaluation of patients with dizziness in the emergency department (ED). ⋯ In the 3-year period studied, CT scans for ED patients with dizziness and vertigo yielded a low predictive value for significant pathology. These data reveal a great opportunity for cost savings by developing stricter guidelines for ordering CT scans for this set of ED patients. The use of MRI in all cases of dizziness was found to be neither practical nor useful. However, appropriately directed MRI of the brain is recommended in patients with dizziness and other neurological signs or symptoms.
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Vertigo or dizziness is primarily caused by peripheral vestibular disorders, such as benign paroxysmal positional vertigo (BPPV) and vestibular neuritis. BPPV can be diagnosed from associated positional torsional or direction-changing horizontal nystagmus and can be treated with canalith repositioning procedures. In contrast, vestibular neuritis and other acute peripheral vestibulopathies can be diagnosed from associated unidirectional horizontal nystagmus. ⋯ This positional enhancement suggests that the same pathogenetic mechanism is involved in both types of nystagmus. The cerebellar lesions may disinhibit both semicircular-ocular and otolith-ocular reflexes. Semicircular-ocular reflex-dominant disinhibitions may result in the ipsilateral horizontal nystagmus, whereas otolith-ocular reflex-dominant disinhibitions may result in the direction-changing apogeotropic positional nystagmus.
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Periodic disorders of childhood often represent precursors of migraine. As we advance our knowledge of migraine and its complicated phenotypic presentation in childhood, we have noted the similarities in overlapping symptoms of children presenting with childhood periodic syndromes. There is often a positive family history of migraine in children that present with periodic syndromes. ⋯ International classification of headache disorders has been instrumental in the evolution of the classification of headache and children adults. The most recent classification utilizes and replaces the periodic symptom terminology with episodic symptoms that will no longer be limited to just childhood. This article will address the evolution of our understanding of the diagnostic criteria, pathophysiology and management of the episodic syndromes that may be associated with migraine.
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Acute continuous vertigo presentations are among the most feared presentations in medicine. Although a self-limited disorder is the typical cause, a life-threatening stroke can also occur. Differentiating a self-limited disorder from a life-threatening stroke can be a challenge. ⋯ A focused oculomotor examination is a necessary component of the assessment, but is underused in routine care. The author describes the challenges to diagnosing stroke in cases of acute continuous vertigo and provides an approach to inform decision making at the bedside. Future research is necessary to validate clinical decision support, assess generalizability, and demonstrate its impact on meaningful outcomes.
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Stroke in the distribution of the posterior circulation may present as acute onset spontaneous vertigo and imbalance. Although vertigo due to posterior circulation stroke is usually associated with other neurologic symptoms or signs, small infarcts in the cerebellum or brainstem can present with vertigo without other localizing symptoms. Approximately 17% of patients with isolated posterior inferior cerebellar artery territory infarction presented with isolated vertigo, nystagmus, and postural unsteadiness. ⋯ Sometimes acute isolated audiovestibular loss can be the initial symptom of impending posterior circulation ischemic stroke (particularly within the territory of the anterior inferior cerebellar artery). In this case, evaluation of isolated audiovestibular loss may prevent the progression of acute vertigo and hearing loss into more widespread areas of infarction in the posterior circulation. In this article, the clinical syndromes and signs of acute vestibular syndrome due to posterior circulation stroke involving the brainstem and cerebellum are summarized.