Often dizzy, don't forget ta! 4 key points to help you avoid the "pit" of misdiagnosis

Considering the doctors, for recurrent transient vertigo, which disease does the following four clues point to?

Clue one: at least 10 spontaneous spin or non-rotational episodes of vertigo;

Clue 2: the duration of symptom onset < 1 minute;

Clue three: carbamazepine and oxcarbazepine treatment is effective;

Clue four: can not be better explained

After reading the clues sorted out by the editor, I believe that the smart doctor friends can already guess one or two, yes, it is vestibular paroxysmia (VP)!

At present, the mainstream academic community believes that VP is a rare disease (incidence <0.

Xiaobian summarized the four major points to help doctors avoid the "pit" of misdiagnosis! Let's take a look at it with Xiaobian

To learn more about vestibular paroxysms, click on the image below to get the full content

Point 1: Focus on the "stereotype" of symptoms, the "transient" of seizures

The main clinical manifestations of VP are recurrent, transient spinish or non-rotational vertigo, usually lasting several seconds, often less than one minute, with stereotypical symptoms ^[6

When the patient presents with "recurrent transient vertigo" as the main complaint and there are clear vascular risk factors, the doctor should first distinguish it from the vertigo caused by posterior circulating ischemia to avoid delaying treatment

In addition, doctors need to pay attention to the number of episodes of vertigo, the duration of each episode, whether it is related to the change of position, and the accompanying symptoms at the time of

Key point 2: Negative signs are an important basis for distinguishing other diseases

Patients with VP usually have no obvious signs, because of their short duration of onset, most of them fail to find significant abnormalities on physical examination, and both ear and neurologic examinations may be negative

Point 3: Master the difference between new and old diagnostic standards, and do not "faint" when seeing a doctor

The diagnosis of VP is mainly based on symptoms, and in 2016 the Parany Association established clinically widely available diagnostic criteria based on the 1984 and 2008 diagnostic criteria ^[4,7], and the differences between the old and new diagnostic criteria are as follows:

A.

b.
The new diagnostic criteria define the time and frequency of attacks;

c.
The new diagnostic criteria do not include the precipitating conditions in the diagnostic elements;

d.
The new diagnostic criteria do not include concomitant symptoms in the diagnostic element;

e.
The new diagnostic criteria include the rigidity of symptoms as a necessary element of the diagnosis;

f.
The new diagnostic criteria elevate the element of carbamazepine and the effectiveness of oxcarbazepine treatment to a more important position
.

Doctors should pay attention to the above changes when using the new diagnostic criteria of VP to diagnose the disease, and cannot generalize the disease
because laboratory tests are non-essential diagnostic elements.

Point 4: Understand these diseases to help you see "halo"

1.
Meniere's disease

The duration of vertigo episodes is 20min to 12 hours, and the onset is accompanied by low- to medium-frequency sensorineural hearing loss, tinnitus, and/or a feeling of
ear tightness.

It is possible to distinguish VP from Meniere's disease based on these two ^{points [8].}

Click here for details such as the diagnosis of Meniere's disease

2.
Vestibular migraine

Patients with vestibular migraine are sensitive to movement during the attack, and changes in the head position or position can also cause transient vertigo, but the duration of the disease is 5min to 72 hours, and there is a history of migraine in the past, and in addition to the symptoms of vertigo at the time of the attack, most of them are accompanied by migraine symptoms
.

VP can be differentiated based on the relatively long duration of the disease, a history of migraine, and migraine symptoms ^[8
].

Click here for details such as the diagnosis of "vestibular migraine"

3.
Isolated vertigo caused by transient ischemic attacks of the vertebrobasilar artery

Transient ischemic attack (TIA) in the posterior circulation may usually be accompanied by signs and symptoms of neurologic deficits, including impaired consciousness, diplopia, dysarthria, dysphagia, cross-paralysis, or sensory impairment
.

Diagnosis can be made rapidly based on the form of onset, symptoms, and localized signs, and can be differentiated from VP, but "isolated central vestibular syndrome" that lacks neurological symptoms or localization signs requires identification with MRI ^[9
].

4.
Vestibular epilepsy

Vestibular epilepsy is a clinical syndrome caused by abnormal firing of neurons in the cortical center of the vestibular system, manifested as a motor or positional illusion caused by episodic, transient, repetitive and stereotyped body spatial localization disorders, in which vestibular aura epilepsy is manifested as vertigo and nystagmus, and vestibular aura with other symptoms, the so-called non-isolated vestibular aura, is more common
than isolated vestibular aura.

Vestibular aura is mainly associated with temporal lobe seizures
.

Isolated vestibular auras usually last only a few seconds, but there are also longer lasting episodes ^[10].


Patients with VP may have evidence of vascular nerve compression, and the current primary treatment for VP is also antiepileptic, but there is no specific EEG
.

Doctors should combine the patient's medical history, experimental treatment and auxiliary examination to make comprehensive judgments to prevent missed diagnosis and generalization
of diagnosis.

5.
Panic attacks

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) states that panic attacks are diagnosed in people with four or more of the following symptoms: palpitations, palpitations, palpitations, or accelerated heart rate; Sweating; Tremor or tremor; Shortness of breath or feeling of suffocation; Choking sensation; Chest pain or chest discomfort; Nausea or abdominal discomfort; Feeling dizzy and unsteady; Chills or feverish sensations; Paresthesias (numbness or pinprick sensation); The disintegration of reality (feeling unreal) or the disintegration of personality (feeling detached from oneself); Fear of losing control or "going crazy"; Feeling of dying
.

These symptoms appear suddenly and peak within minutes
.

Panic attacks usually last longer
than VP attacks.

The doctor should ask the patient about the order in which symptoms appear, which can help distinguish
from VP.

6.
Inner ear "third window" disease

It mainly includes external lymphoid fistula and superior canal cleft syndrome
.

Exolymphoid fistula is often caused by inflammation of the ear, and superior canal cleft syndrome is often caused
by trauma.

The core symptoms of this type of disease are vertigo attacks caused by changes in stress or noise, and the triggers include coughing, pressing the ear screen, sneezing, weightlifting, or noise irritation, which can be accompanied by visual oscillations, postural abnormalities, and gait instability
.

These symptoms may last from seconds to days and can occur when the patient's head position changes (e.
g.
, bending over) and when experiencing significant changes in height (e.
g.
, mountain travel, flight) ^[11].


Imaging studies may reveal bone discontinuities
at the appropriate location.

Physician partners differentiate VP
based on their history, triggers, and radiographic findings.

7.
Episodic ataxia

The duration of episodic ataxia type 2 episodes varies from a few minutes to a few hours, and more than 90% of these patients have cerebellar signs, particularly gaze-induced nystagmus and bouting nystagmus
.

Most patients develop symptoms
before the age of 20.

Episodic ataxia type 1 is more rare and is characterized by recurrent episodes of ataxia, dizziness, and blurred vision, with symptoms that gradually decrease with age, ranging from seconds to minutes, and sometimes for hours, up to dozens of episodes per day ^[12].

summary

Diagnosis of VP is difficult and relies heavily on its clinical symptoms
.

In clinical practice, diagnosis can be assisted by a combination of audiology-related tests, vestibular function, and typical imaging findings
.

VP is characterized by narcolepsy vertigo lasting <1 minute, frequent seizures with more than 10 episodes, abnormalities in audiology and vestibular function, neovascular compression (NVC) in the mri of the internal auditory tract, and antiepileptic drugs to verify the effectiveness<b14> of treatment.

According to the above points, and combined with the above other disease identification points, the doctor's small partner can avoid misdiagnosis
to the greatest extent.

Regarding the basics, diagnostic criteria, treatment, etc.
of "Vestibular Paroxysmal Disease", you can click on the following figure to obtain the complete content
with one click.

References:

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Long-term outcome of vertigo and dizziness associated disorders following treatment in specialized tertiary care: the Dizziness and Vertigo Registry (DiVeR) Study[J].
J Neurol, 2015, 262(9): 2083-2091

[2] Strupp M, Dieterich M, Brandt T.
The treatment and natural course of peripheral and central vertigo[J].
Dtsch Arztebl Int, 2013, 110(29-30): 505-15; quiz 515-6.

Xue Hui,Chongyi,Jiang Zidong.
Etiological analysis of patients with vertigo/dizziness in neurology[J].
Chinese Medical Journal, 2018, 98(16): 1227-1230.

[4] Hüfner K, Barresi D, Glaser M, et al.
Vestibular paroxysmia: diagnostic features and medical treatment[J].
Neurology, 2008, 71(13): 1006-1014.

[5] Lehnen N, Langhagen T, Heinen F, et al.
Vestibular paroxysmia in children: a treatable cause of short vertigo attacks[J].
Dev Med Child Neurol, 2015, 57(4): 393-396.

[6] Brandt T, Strupp M, Dieterich M.
Vestibular paroxysmia: a treatable neurovascular cross-compression syndrome[J].
J Neurol, 2016, 263(1): S90-S96.

[7] Strupp M, Lopez-Escamez JA, Kim JS, et al.
Vestibular paroxysmia: Diagnostic criteria[J].
J Vestib Res.
2016, 26(5-6): 409-415.

[8] Lopez-Escamez JA, Carey J, Chung WH, et al.
Diagnostic criteria for Meniere’s disease[J].
J Vestib Res, 2015, 25(1): 1-7.

[9] Paul N L, Simoni M, Rothwell P M.
Transient isolated brainstem symptoms preceding posterior circulation stroke: A population-based study[J].
Lancet Neurol, 2013, 12(1): 65-71.

[10] Brandt T,  Dieterich M, Strupp M.
Vertigo and dizziness : common complaints[J].
Springer Ebooks, 2012.

[11] Jen JC, Graves TD, Hess EJ,et al.
Griggs and R.
W.
Baloh, Primary episodic ataxias: Diagnosis, pathogenesis and treatment[J].
Brain, 2007, 130(Pt 10): 2484-2493.

[12] Tarnutzer AA, Lee SH, Robinson KA,et al.
Newman-Toker, Clinical and electrographic fifindings in epileptic vertigo and dizziness: A systematic review[J].
Neu rology, 2015,84(15): 1595-1604.

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