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Vertigo and dizziness in the emergency room.
Zwergal, A, Dieterich, M
Current opinion in neurology. 2020;(1):117-125
Abstract
PURPOSE OF REVIEW To provide an update on diagnostic algorithms for differential diagnosis of acute vertigo and dizziness and swift identification of potentially harmful causes. RECENT FINDINGS About 25% of patients with acute vertigo and dizziness have a potentially life-threatening diagnosis, including stroke in 4-15%. Diagnostic work-up relies on the combination of symptom features (triggers, duration, history of vertigo/dizziness, accompanying symptoms) and a comprehensive vestibular, ocular motor, and balance exam. The latter includes head impulse, head-shaking nystagmus, positional nystagmus, gaze-holding, smooth pursuit, skew deviation, and Romberg's test. Recent standardized diagnostic algorithms (e.g., HINTS, TriAGe+) suggest the combination of several elements to achieve a good diagnostic accuracy in differentiation of central and peripheral vestibular causes. Neuroimaging with MRI must be applied and interpreted with caution, as small strokes are frequently overlooked, especially in the acute setting (false-negative rate of up to 50%). SUMMARY Diagnostic differentiation of acute vertigo and dizziness remains a complex task, which can be tackled by a structured clinical assessment focusing on symptom characteristics and constellations of ocular motor and vestibular findings. Specific challenges arise in cases of transient or atypical vestibular syndromes.
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Weak and Dizzy-Another Explanation to Explore: Poor Nutrition in the Older Adult.
Somes, J
Journal of emergency nursing. 2020;(4):541-545
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3.
Herbal medicine for cervicogenic dizziness: A protocol for a systematic review and meta-analysis.
Oh, H, Shin, S, Lee, E
Medicine. 2020;(51):e23852
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Abstract
BACKGROUND Herbal medicines are empirically used to treat cervicogenic dizziness. However, till date there have been no systematic review to evaluate the efficacy and safety of these medicines. Therefore, this study protocol describes the methods for evaluating the efficacy and safety of herbal medicine for cervicogenic dizziness. METHODS AND ANALYSIS The following electronic academic databases will be searched up to December 2019 without language or publication status restrictions: Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica database (EMBASE), and the Cochrane Central Register of Controlled Trials (CENTRAL), together with Korean, Chinese, and Japanese databases. Any randomized controlled trials related to herbal medicine for cervicogenic dizziness will be included. The functional outcomes and the vertebrobasilar artery hemodynamic states will be evaluated as primary outcomes. The total effective rate, hematological conditions, and adverse events will be assessed as secondary outcomes. Study selection, data extraction, quality assessment of studies, and qualitative evaluation of clinical evidence will be performed by 2 independent reviewers. The methodological quality of the included studies will be evaluated using a revised Cochrane risk-of-bias tool for randomized trials. The strength of evidence from the included data will be evaluated using the Grading of Recommendations Assessment, Development, and Evaluation approach. Data synthesis will be performed as either a fixed-effects or a random-effects model using Review Manager software version 5.3. The results will be reported as a risk ratio for dichotomous outcomes and as a mean difference or standardized mean difference for continuous outcomes. ETHICS AND DISSEMINATION No ethical approval is required since the individual clinical information of the patient is not used. The findings of this systematic review will be disseminated through the peer-reviewed publications or conference presentations. REVIEW REGISTRY UNIQUE IDENTIFYING NUMBER reviewregistry1036.
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Effect of Prophylactic Medication on Associated Dizziness and Motion Sickness in Migraine.
Lee, SH, Jeong, SH, Kim, JS, Kim, HJ, Choi, KD, Choi, JH, Oh, SY, Park, JY, Kim, DU, Kim, BK
Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology. 2018;(1):e45-e51
Abstract
OBJECTIVE To determine the efficacy of prophylactic medications for migraine in reducing associated dizziness and motion sickness. STUDY DESIGN Multicenter prospective observational study. SETTING Nationwide 9 Dizziness Clinics in South Korea. PATIENTS One hundred thirty-eight patients who required a preventive medication for migraine accompanied by dizziness and motion sickness. INTERVENTION At least one of the prophylactic medications was prescribed among the beta-blockers, calcium channel blockers, tricyclic antidepressants, and antiepileptic drugs. MAIN OUTCOME MEASURE For 3 months from the index visit, the patients had monthly assessments of the headache (frequency and duration), dizziness handicap inventory, University of California Los Angeles dizziness questionnaire, vertigo symptom scale, and motion sickness score. RESULTS The prophylactic medications significantly improved the headache profiles, all three parameters of dizziness (dizziness handicap inventory, University of California Los Angeles dizziness questionnaire, and vertigo symptom scale), and severity of motion sickness (p < 0.001). CONCLUSION The prophylactic medication for migraine also improves associated dizziness and motion sickness as well as the headaches.
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Ginkgo biloba extract EGb 761® alleviates neurosensory symptoms in patients with dementia: a meta-analysis of treatment effects on tinnitus and dizziness in randomized, placebo-controlled trials.
Spiegel, R, Kalla, R, Mantokoudis, G, Maire, R, Mueller, H, Hoerr, R, Ihl, R
Clinical interventions in aging. 2018;:1121-1127
Abstract
BACKGROUND Tinnitus and dizziness are frequent in old age and often seen as concomitant symptoms in patients with dementia. In earlier clinical trials, Ginkgo biloba extract EGb 761® was found to alleviate tinnitus and dizziness in elderly patients. Consequently, a meta-analysis was conducted to evaluate the effects of EGb 761® at a daily dose of 240 mg on tinnitus and dizziness associated with dementia. METHODS Randomized, placebo-controlled clinical trials of G. biloba extract EGb 761® identified by a systematic database search were included in a meta-analysis if they met all of the following selection criteria: 1) diagnosis of dementia according to generally accepted criteria, 2) treatment period of at least 20 weeks, 3) outcome measures covering at least two of the three conventional domains of assessment, 4) presence and severity of dizziness and tinnitus were assessed, and 5) assessment was done before and after randomized treatment. RESULTS Five trials that met the inclusion criteria were included in the meta-analysis. The risk of bias was judged as low, with Jadad scores of 3 and 5. In all trials, 11-point box scales were used to assess the severity of tinnitus and dizziness. Overall, EGb 761® was superior to placebo, with weighted mean differences for change from baseline, calculated in meta-analyses using random effects models, of -1.06 (95% CI: -1.77, -0.36) for tinnitus (p = 0.003) and -0.77 (95% CI: -1.44, -0.09) for dizziness (p = 0.03). CONCLUSION Our findings support the notion that EGb 761® is also effective in alleviating concomitant neurosensory symptoms in patients with dementia.
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EARLY-ESLI study: Long-term experience with eslicarbazepine acetate after first monotherapy failure.
Villanueva, V, Bermejo, P, Montoya, J, Toledo, M, Gómez-Ibáñez, A, Garcés, M, Vilella, L, López-González, FJ, Rodriguez-Osorio, X, Campos, D, et al
Acta neurologica Scandinavica. 2017;(3):254-264
Abstract
PURPOSE Evaluate real-life experience with eslicarbazepine acetate (ESL) after first monotherapy failure in a large series of patients with focal epilepsy. METHOD Multicentre, retrospective, 1-year, observational study in patients older than 18 years, with focal epilepsy, who had failed first antiepileptic drug monotherapy and who received ESL. Data from clinical records were analysed at baseline, 3, 6 and 12 months to assess effectiveness and tolerability. RESULTS Eslicarbazepine acetate was initiated in 253 patients. The 1-year retention rate was 92.9%, and the final median dose of ESL was 800 mg. At 12 months, 62.3% of patients had been seizure free for 6 months; 37.3% had been seizure free for 1 year. During follow-up, 31.6% of the patients reported ESL-related adverse events (AEs), most commonly somnolence (8.7%) and dizziness (5.1%), and 3.6% discontinued due to AEs. Hyponatraemia was observed in seven patients (2.8%). After starting ESL, 137 patients (54.2%) withdrew the prior monotherapy and converted to ESL monotherapy; 75.9% were seizure free, 87.6% were responders, 4.4% worsened, and 23.4% reported ESL-related AEs. CONCLUSION Use of ESL after first monotherapy failure was associated with an optimal seizure control and tolerability profile. Over half of patients were converted to ESL monotherapy during follow-up.
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The dizzy patient: don't forget disorders of the central vestibular system.
Brandt, T, Dieterich, M
Nature reviews. Neurology. 2017;(6):352-362
Abstract
Vertigo and dizziness are among the most common complaints in neurology clinics, and they account for about 13% of the patients entering emergency units. In this Review, we focus on central vestibular disorders, which are mostly attributable to acute unilateral lesions of the bilateral vestibular circuitry in the brain. In a tertiary interdisciplinary outpatient dizziness unit, central vestibular disorders, including vestibular migraine, comprise about 25% of the established diagnoses. The signs and symptoms of these disorders can mimic those of peripheral vestibular disorders with sustained rotational vertigo. Bedside examinations, such as the head impulse test and ocular motor testing to determine spontaneous and gaze-evoked nystagmus or skew deviation, reliably differentiate central from peripheral syndromes. We also consider disorders of 'higher vestibular functions', which involve more than one sensory modality as well as cognitive domains (for example, orientation, spatial memory and navigation). These disorders include hemispatial neglect, the room tilt illusion, pusher syndrome, and impairment of spatial memory and navigation associated with hippocampal atrophy in cases of peripheral bilateral vestibular loss.
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In vivo neurometabolic profiling in orthostatic tremor.
Benito-León, J, Louis, ED, Mato-Abad, V, Dydak, U, Álvarez-Linera, J, Hernández-Tamames, JA, Molina-Arjona, JA, Malpica, N, Matarazzo, M, Romero, JP, et al
Medicine. 2016;(37):e4848
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Abstract
The pathogenesis of orthostatic tremor (OT) remains unclear, although some evidence points to dysfunction in the brainstem or cerebellum. We used single voxel proton magnetic resonance spectroscopy (1H-MRS) (3 T) to investigate whether neurochemical changes underlie abnormal cerebellar or cortical function in OT. Fourteen OT patients and 14 healthy controls underwent 1H-MRS studies with voxels placed in midparietal gray matter and cerebellum (vermis and central white matter). Spectral analysis was analyzed using the software package LCModel (version 6.3). The absolute metabolite concentrations and ratios of total N-acetylaspartate + N-acetylaspartyl glutamate (NAA), choline-containing compounds, myoinositol, and glutamate + glutamine to creatine were calculated. In midparietal gray matter spectra, we found a significant decrease in the absolute concentration of NAA in OT patients versus healthy controls (7.76 ± 0.25 vs 8.11 ± 0.45, P = 0.017). A similar decrease in NAA was seen in the cerebellar vermis (7.33 ± 0.61 vs 8.55 ± 1.54, P = 0.014) and cerebellar white matter (8.54 ± 0.79 vs 9.95 ± 1.57, P = 0.010). No differences in the other metabolites or their ratios were observed. Reductions in both cerebral cortical and cerebellar NAA suggest that there is neuronal damage or loss in OT, raising the intriguing question as to whether OT is a neurodegenerative disease. Along with clinical history and electrophysio0logical examination, 1H-MRS could serve as a useful diagnostic aid for OT.
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Medical and Nonstroke Neurologic Causes of Acute, Continuous Vestibular Symptoms.
Edlow, JA, Newman-Toker, DE
Neurologic clinics. 2015;(3):699-716, xi
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Abstract
Most patients with the acute vestibular syndrome (AVS) have vestibular neuritis or stroke or, in the setting of trauma, a posttraumatic vestibular cause. Some medical and nonstroke causes of the AVS must also be considered. Multiple sclerosis is the most common diagnosis in this group. Other less common causes include cerebellar masses, inflammation and infection, mal de debarquement, various toxins, Wernicke disease, celiac-related dizziness, and bilateral vestibulopathy. Finally, there may be unmasking of prior posterior circulation events by various physiologic alterations such as alterations of temperature, blood pressure, electrolytes, or various medications, especially sedating agents.
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Case of levodopa toxicity from ingestion of Mucuna gigantea.
Tse, GG, Kim, BB, McMurtray, AM, Nakamoto, BK
Hawai'i journal of medicine & public health : a journal of Asia Pacific Medicine & Public Health. 2013;(5):157-60
Abstract
Hawai'i is home to 1000 native species of flowering plants. Mucuna gigantea is one such Hawaiian species which has been studied as affordable sustenance and as a cover crop in developing countries. Mucuna gigantea and other Mucuna species (spp.) in general, are known to contain natural levodopa and its utility in the treatment of Parkinson's Disease has also been evaluated. Levodopa is converted in the periphery into dopamine which can then act on dopamine receptors to cause nausea, vomiting, arrhythmias, and hypotension. We describe a case in which a patient presents with abdominal pain, nausea, and vomiting after legume ingestion. The bean was ultimately identified as Mucuna gigantea and the patient was diagnosed with levodopa-induced gastrointestinal toxicity from consumption of the legume. A literature review was conducted using the database search engines, Biological Abstracts and PubMed, with a broad combination of keywords of which include "mucuna, "gigantean," "levodopa," "l-dopa," "toxicity," and the association between Mucuna gigantea ingestion and levodopa toxicity is discussed. These findings expand the differential diagnosis of abdominal pain associated with nausea and vomiting in the correct clinical context.