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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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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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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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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.