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Tumor Labyrinthitis
Benign positional
vertigo: #1 cause of
peripheral vertigo
Episodic symptoms
Free floating debris
in semicircular
canals
Dix-Hallpike maneuver:
diagnostic and therapeutic
• Positional vertigo:
•Vertigo/nystagmus reproduced
•Latency 5-15 seconds
•Decreases w/in 30 seconds
•Fatigues on repeat
Vertigo: when to image?
Rule out tumor
1/9307 - dizziness, normal hearing
Indications
New neuro symptoms/signs
Sudden vertigo & stroke risk factors
Vertigo & new severe headache
Test of choice: MRI/ MRA
Gizzi, Arch Neurol 1996
Case: unsteadiness
A 78 year old woman with coronary artery disease,
type 2 diabetes, cataracts, anxiety and depression
has chronic dizziness - “unsteady while walking”
Meds: insulin, lovastatin, atenolol, fludrocortisone,
prozac
Neuro exam: slightly wide based gait. DTRs absent in
ankles. Reduced vibration sense to ankle bilaterally.
Short of breath with neuro exam maneuvers.
Disequilibrium: often multifactorial
Sense of imbalance -worse with walking
Contributing factors
Vision, hearing impairment
Peripheral neuropathy
Musculoskeletal disease/gait disturbance
Medications
Dizziness: a geriatric syndrome
24% of community-living elders had dizziness > 1 month
Differential diagnosis:
coma
narcolepsy
seizure
Syncope: scope of the problem
Common
3% Emergency Department visits
1-6% hospital admissions
Costly
Multiple diagnostic tests often performed
Average charge for each diagnostic test ranges
from $284 to $4678
Linzer, Ann Intern Med, 1997
Diagnostic Challenges
History often unclear
Prognosis varies widely
Common etiologies are benign
Diagnosis?
Plan - Admit? Further testing?
Glassman, Arch Intern Med, 1997
Etiology of Syncope
Idiopathic 34%
Neurally-mediated
Vasovagal 18%
Other (situational, carotid sinus) 6%
Cardiac
Arrhythmia 14%
Mechanical 4%
Neurologic 10%
Orthostatic 8%
Medications 3%
Psychiatric 2%
Linzer, Ann Intern Med, 1997
Risk Factors
Predictors of arrhythmic syncope or
cardiac death at one year
CHF
Ventricular tachyarrhythmias
Abnormal ECG
Age >45 years
Presence of 2 or more of these is
associated with >10% incidence of
syncope or cardiac death
Cardiac Differential
Cardiac Syncope: LOC often w/o prodrome
Indicates Outflow Obstruction
AS, HOCM, PAH, Pulmonic Stenosis, PE
MI, USA, Coronary Artery Spasm, Aortic
Dissection
Arrhythmias
Prolonged QT (either Congenital or Drug Induced)
AV Block, Sinus Node Dysfunction
Ventricular tachycardia
Arrhythmogenic right ventricular dysplasia
Supraventricular tachycardia (Wolff-Parkinson-White)
Neurally Mediated Syncope
Most Common Causes
Vasovagal, Situational, and Carotid
Sinus Syncope
Results from sudden reflex mediated
hypotension/ and or bradycardia
Triggered by various stretch/
mechanoreceptors (carotid sinus,
bladder, esophagus, respiratory tract
Carotid Sinus Syncope and Autonomic Dysfunction
1 2 3 4
• VVS • Drug-Induced • Brady • Acute
• CSS • ANS Failure SN Myocardial
Dysfunction Ischemia
• Situational Primary
AV Block • Aortic
Cough Secondary
• Tachy Stenosis
Post-
VT • HCM
Micturition
SVT • Pulmonary
• Long QT Hypertension
Syndrome • Aortic
Dissection
Syncope
Noncardiac Idiopathic
Cardiac
Arrhythmia Neurocardiogenic
Mechanical Orthostatic
Neurologic
Psychiatric
Cardiac syncope:
inadequate cardiac output, arrhythmia
Cardiac enzymes - only if history or EKG suggestive of MI
– 1-10% MI’s present with syncope
– EKG up to 100% sensitive for MI
Echo - rule out structural heart disease
– before stress test if obstruction suspected
– yield: 5-10%
Exercise stress test - exertional syncope
– identifies exertional arrhythmia
– yield: low (1%)
Georgeson, J Gen Intern Med, 1992
Linzer, Ann Intern Med, 1997
Arrhythmia evaluation - telemetry
Indication: suspected arrhythmia
palpitations, no prodrome
10% syncope/dizzy
all syncope
ICU transfer-arrhythmia 0.8% 0.4%
Telemetry “Helpful” 12.6% 16%
Mortality 0.9% 0
Estrada, Am J Cardiol, 1995
Linzer, Ann Intern Med, 1997
Estrada, Am J Cardiol, 1995
Arrhythmia evaluation:
24 hr ambulatory (Holter) monitoring
• Diagnostic arrhythmia in 4%
Bottom line
• Benefit: monitors during usual activity
– Loop recorder
– Indication: recurrent syncope with normal heart
Neurocardiogenic
Syncope
Vasovagal
Carotid sinus syncope
Neurally - mediated
Cardioneurogenic
Neurocardiogenic Syncope
Clinical Presentation
140 Trigger
May be predominantly 120
Cardioinhibitory
100
(bradycardia)
80 Blood
Vasodepressor pres sure
60 Pulse
(hypotension) or
40
Both Syncope
20
0
2 4 6 8
time (minutes)
Neurocardiogenic Syncope:
Pathophysiology
Decreased venous return
Increased LV contractility
Mechanoreceptor
Stimulation
Inhibits Increases
Sympathetic tone Vagal tone
Vasodilation Bradycardia/
Asystole
Hypotension SYNCOPE
SYNCOPE
Diagnosing neurocardiogenic
syncope by history and exam
Precipitant
Vasovagal: pain, emotion, standing
Situational: vagal stimulus
Autonomic symptoms
Rapid recovery of mental status
Bradycardia, pallor may persist
Carotid sinus massage
>3 sec asystole or hypotension=hypersensitivity
Syncope: management questions
Diagnostic challenges
What is the best diagnostic test?
Management dilemmas
Neurocardiogenic syncope: treatment
Medications
B blocker, SSRI, midodrine, fludrocortisone
Pacemaker
Vasovagal syncope: pacemakers ineffective
*p<0.01
NEJM 2002;347:878
Prognosis:
ED risk stratification
98% sensitive
T IFF (Unc om pres s ed) dec om pres s or
are needed to s ee t his pic t ure.
56% specific
CHF - history of
QuickTime™ and a
TIFF ( Uncompressed) decompressor
ECG abnormal
Shortness of breath
Systolic blood pressure <90 mm
Hg at triage
Quinn, Ann Emerg Med, 2006
ACP Guidelines for Hospital
Admission
arrhythmia, bundle
branch block Linzer, Ann Intern Med, 1997
Guidelines for Hospital Admission:
implications for practice
Myth: Every syncope patient should be admitted
Recommendation: Establish clear goals for admission,
usually diagnostic
Situational syncope
40
35
elderly-cardiac syncope
30
25
elderly-noncardiac
20
%
syncope
15
young-cardiac syncope
10
5
young-noncardiac
0 syncope
0 3 6 9 12 15 18 21 24
Months
Kapoor, Am J Med, 1986
Dizziness: key points
Vertigo is most common etiology
Positional triggers, nystagmus help confirm
peripheral etiology
Neuro findings, stroke risk prompt imaging
Disequilibrium - commonly due to
multifactorial deficits in elderly
Presyncope - manage like syncope
Syncope: key points
History, exam, EKG guide further testing
Identify possible cardiac syncope early
Admit if high risk of cardiac disease
Neurocardiogenic syncope - diagnosed
clinically or by tilt table
Idiopathic syncope has multiple etiologies
and good prognosis