 Home > Active Ingredient News > Study of Nervous System > Vertigo time · Stage 1 History of patients with vertigo/vestibular disease

Vertigo time · Stage 1 History of patients with vertigo/vestibular disease

 Last Update: 2022-11-01
 Source: Internet
 Author: User

Tags

sedalia medical center

medical refrigerator

Search more information of high quality chemicals, good prices and reliable suppliers, visit www.echemi.com

Vertigo/vestibular disease has a high incidence and complex etiology involving multidisciplinary knowledge
.
As an interdisciplinary discipline, the diagnosis and treatment of vertigo/vestibular disorders is attracting increasing attention
from multidisciplinary physicians and researchers.
With the deepening of clinical diagnosis and treatment, how to further promote the rapid development of vertigo/vestibular medicine in clinical diagnosis and treatment standards is imminent! In order to further promote the exchange and dissemination of vertigo professional knowledge in China, Yimaitong and multidisciplinary experts from the Vertigo/Vestibular Medicine Branch of the Chinese Geriatrics Society launched a special column on the theme of "vertigo time", hoping to provide more exciting clinical knowledge points for students across the country to learn
.

In the first phase, Professor Yang Xu from Aerospace Center Hospital (Peking University School of Aerospace Clinical Medicine) was invited to share
the content of "History Collection of Patients with Vertigo/Vestibular Disease".

Expert profiles

Prof.
Xu Yang

Aerospace Center Hospital (Peking University School of Aerospace Clinical Medicine)

Chief physician, professor of Peking University Health Science Center, graduate supervisor, deputy director of the Department of
Neurology.
President of Vertigo/Vestibular Medicine Branch of Chinese Geriatrics Association, Vice Chairman of Encephalopathy Special Committee of China Association of Chinese Materia Medica, Vice Chairman of Vertigo Prevention and Control Collaborative Innovation Community of Chinese Society of Traditional Chinese Medicine, Member of Vertigo Collaboration Group of Chinese Medical Association Neurology Branch, Member of Evidence-Based Medicine Professional Committee of Chinese Medical Doctor Association, and Standing Committee Member of Several Other Related Vertigo Special Committees; Beijing Municipal Science and Technology Commission medical and health field and initial fund review expert, deputy editor-in-chief of
"Stroke and Neurological Diseases".

A number of clinical research data platforms have been initiated, including the diagnosis and mechanism of positional nystagmus (BPPV/light crest/CPPV) and vertical nystagmus, the accurate diagnosis of various vestibular evaluation techniques and imaging, neuro-ocular otology & otolith gravity pathway & eye movement diagnosis, the development of predictive models for central vascular vertigo, EA2 gene diagnosis, brain function & brain network changes in VM/PPPD/MD, The central dynamic compensation mechanism related to vestibular rehabilitation has been studied
in depth.
In recent years, he has published nearly 30 research results
related to vertigo/vestibular disease in internationally renowned journals such as Journal of Neurology and NeuroImage: Clinical.
He has been awarded as "Excellent Tutor of Graduate Students" and "Top Ten Experts"
of the hospital for many times.
He has presided over more than 20 projects such as the first launch and northern nature, and supervised more than 30 master's/doctoral students
.
He has published 130 papers in
Chinese and English.

1.
Objectives and content of medical history collection

➤ Vertigo/Vestibular Disease Etiology: Includes peripheral/central vestibular lesions – there are two major types of diseases
: structural/non-structural.

➤ Vertigo/Vestibular Disease Diagnostic Procedure: History Collection (2022 Edition).

(1) Medical history collection goals & value
✔ History collection goals: infinitely close to the pathophysiological evolution of the disease itself and to determine the diagnosis
.
✔ Clinical diagnosis of diseases: vestibular/non-vestibular diseases - AVS, EVS, CVS - further obtain clinical preliminary diagnosis, including localization diagnosis and etiological mechanism speculation; In addition, especially for diseases such as VM and PPPD that take symptomatology as the core of diagnosis, medical history collection is more important
.
✔ Assessment of treatment prognosis: in addition to helping to diagnose, cause and mechanism discovery, it also helps to obtain relevant information about
treatment and prognosis.
✔ Provide mutual verification: it can also provide ideas for targeted selection of bedside physical examination and evaluation techniques; At the same time, mutual verification
can be carried out.

(2) Relevant content of medical history collection 1.
Chief complaint + present medical history:
(1) form of onset; (2) Core symptoms: including the consultation of the main complaint symptoms and the four major symptoms related to vestibular disease, which is the core content of the specialty consultation; (3) duration; (4) predisposing factors; (5) accompanying symptoms; (6) differential symptoms; (7) dynamic evolution: including the diagnosis and treatment of the disease, the development and evolution of the disease, and the changes
in the general condition since the onset of the disease.
2.
Basic medical history: (1) past history:
(A) review of past diseases; (B) history of infectious diseases and vaccination; (C) history of surgery, trauma and blood transfusion (D) history of drug allergy; (2) Personal history: (A) contact history in epidemic and pastoral areas; (B) occupation and working conditions; (C) living habits and hobbies; (D) history of metallurgy; (3) Marital history: spouse's health status, etc.
; (4) menstrual history/fertility history; (5) Family history: (A) whether family members have similar diseases; (B) whether there are infectious diseases and hereditary diseases
in the family.

2.
Interpretation of eight contents of medical history collection

(1) Complaints + examination of current medical history 1.
Such as: vestibular migraine "halo" examination (1) As Barany Society classifies vestibular symptoms, vestibular symptoms that meet the diagnosis of vestibular migraine include: (1) Spontaneous vertigo: including internal vertigo (illusion of self-movement) and external vertigo (visual rotation or floating The illusion of movement); (2) Positional vertigo: occurs after head position change; (3) Visually-induced vertigo: induced by complex or large-scale active visual stimuli; (4) Vertigo induced by head activity: occurs when the head is active; (5) Head activity-induced dizziness with nausea: Dizziness is characterized by the perception of impaired spatial orientation, and other forms of dizziness are not currently included in the
classification of vestibular migraine.

(2) Those whose vestibular symptoms have reached the influence but have not yet prevented the degree of daily activity are defined as moderate, and those who prevent the degree of daily activity are determined as severe
.

(3) The duration of seizures is highly variable: about 30% of patients are minutes, 30% of patients are hours, another 30% are days, and the remaining 10% are seconds, especially after head movement, visual stimulation or head position changes
.
In this patient, seizure duration is defined as the total time
during which recurrent transient episodes were present.
In contrast, it may take weeks for patients to fully recover
from a single seizure.
However, core seizures rarely last longer than 72 hours
.

2.
Main complaint + present medical history key points (1) Onset form: acute? Episodic? Chronic? ---- the basis
for the diagnosis of AVS/EVS/CVS.
But sometimes it is important to note that the illusions overlap: AVS is EVS, EVS is AVS, the same patient, different forms of seizures
at different times.

(2) Core symptoms: including the four vestibular symptoms of ICVD (dizziness, dizziness, vestibular vision and posture symptoms) and other symptoms complained by patients this time, most patients complain of the two are unified
.
Note that the main symptom of the patient's visit is not necessarily one of the four vestibular symptoms of ICVD; It is important to consult the four major symptoms associated with vestibular disease - pay attention to distinguish confusion, presyncope and syncope state, unstable feeling without vestibular impairment, and a sense of disengagement from reality (depersonalization and deintegration of reality).

(3) Duration: seconds/minutes/hours/days, months/duration
.

(4) Predisposing factors: such as dizziness/dizziness, position, head movement, uprightness, vision, sound, Valsalva movements and pressure and other induces; Of course, there are other triggers
that have a clear temporal relationship with the onset of vertigo.

(5) Accompanying symptoms: accompanied by symptoms related to neurology/ophthalmology/otology/psychiatric psychology and internal medicine systems, and carry out localization and qualitative differential diagnosis
.

(6) Differential symptoms: Accurate diagnosis of diseases related to diseases that tend to be diagnosed
.

(7) Dynamic evolution: including the diagnosis and treatment of diseases, the development and evolution of diseases, and the changes in general conditions since the
onset of disease.

Among them, the consultation of vestibular symptoms and differential diagnosis of ICVD is the core and very important
.

(2) Consultation of basic medical history (past history, personal history, marriage and childbearing history, family history, etc.
)
1 Key points of basic medical history ➤ Pay attention to the diagnosis to find the basis of the disease: vascular mediation; immunoinflammatory; trauma-related; Tumor degeneration; Metabolism in intoxication; Innate heredity
.
(1) Past medical history: (A) review of past diseases, (B) history of infectious diseases and vaccinations, (C) history of surgery, trauma and blood transfusion, (D) history of drug allergy; (2) Personal history: (A) contact history in epidemic and pastoral areas; (B) occupation and working conditions; (C) living habits and hobbies; (D) history of metallurgy; (3) Marital history: spouse's health status, etc.
; (4) menstrual history/fertility history; (5) Family history: (A) whether family members have similar diseases; (B) whether there are infectious diseases and hereditary diseases
in the family.
➤ "Midnights" principle: M--metabolism metabolic/malnutrition disorders; I--inflammation/immune, inflammatory/immune; D--degeneration, degeneration; N--neoplasm, tumor; I--infection, infection; G--gland, glandular, endocrine; H--hereditary, genetic; T--toxication, poisoning/trauma, trauma; S--stroke, stroke
.
2.
Summary: Relevant contents and key points of medical history collection (1) Eight questions of medical history collection: A.
Chief complaint/present medical history:
onset form + core symptoms (the main symptoms of this visit; It also includes information collection, differential symptoms, and dynamic outcomes of diagnosis and treatment of core symptoms of vestibular impairment (vertigo/dizziness/vestibulo-visual symptoms/postural symptoms) and their associated duration, precipitating factors (spontaneous or prevoked onset), and accompanying symptoms (especially neurological symptoms, hearing, psychiatric and medical symptoms); B.
Other basic medical history: including basic information
such as past history, personal history, marriage and childbearing history, drug history and family history.
(2) Key points of advanced consultation: A.
Pay attention to localization and mechanism diagnostic information collection: including peripheral/central vestibule/psychiatric and functional/internal medicine (vascular, inflammatory, immunological, metabolic poisoning?) --Peripheral/central, acute/episodic/chronic? B.
Pay attention to diagnostic criteria and differential information collection: differential diagnosis information consultation - optimal tendency diagnosis; C.
Pay attention to optimizing the strategies and techniques of medical history collection: (a) first coarse and then detailed examination, especially for chronic and recurrent patients; (b) if it is an ineffective consultation, it can be by: retrospective previous examination method, new examination to find clues, dynamic follow-up diagnosis method; (c) sometimes pay attention to the evolution of secondary and comorbid diagnosis strategies
.

3.
ICVD symptom/differential symptom consultation

(i) ICVD vestibular symptom classification 1 Vertigo: Motion illusion (rotation (mostly related to damage to the semicircular canal) and non-rotation (linear movement, tipping---, rocking, tipping, floating, bouncing or slipping).

spontaneous vertigo (internal: spinning and non-spinning); Induced vertigo (position/head movement/vision/sound) 2 Dizziness: impaired
spatial orientation.
Spontaneous dizziness; induced dizziness (position/movement/vision/sound); Both can occur in vestibular or non-vestibular disorders, either acute or chronic
.
Cerebral vertigo/dizziness refers to the process of
head movement.
Positional vertigo/dizziness is induced by the position of the head after a change in space relative to gravity
.
3.
Postural: Balance symptoms associated with maintaining postural stability and occur
only in the upright position.
However, it does not refer to symptoms
caused by changes in body position relative to gravity.
instability; directional dumping; Balance almost falls; Balance falls
.
4.
Vestibulovisual: A visual symptom produced by vestibular pathology or the interaction between the visual-vestibular system, but not referred to as visual hallucinations
.
External vertigo; visual oscillation; Optic lag/optic tilt; Motor visual blur Note: Minor symptoms associated with vestibular disorders need to be distinguished: confusion, presyncope and syncope state, instability without vestibular impairment, feelings of disengagement from reality (depersonalization and deintegration of reality), and motion sickness
.
VOR (vestibulo-ocularreflex): vestibular ocularreflex; VSR (vestibulo-spinalreflex): vestibulospinal reflex
.

Standardize the interpretation of these core symptoms and contribute to international communication and professional understanding.

1.
Clarified the definition and scope of
vertigo and dizziness.
Emphasize that these symptoms can coexist or occur
sequentially.
Vertigo, commonly referred to as "internal" vertigo, as distinct from "extrinsic" motor visual sensations (attributed to vestibulo-visual symptoms), includes both rotational and non-rotational sensations
.
Dizziness, on the other hand, is impaired spatial orientation or a sense of obstruction, and there is no false or distorted sense
of movement.
At the same time, it is pointed out that dizziness is not used to describe feelings such as confusion, presyncope and fainting state, feelings
of disengagement from reality (depersonalization and decomposition of reality), and weakness and dizziness.
The terms
non-specific dizziness and lightheadedness are no longer used.
2.
Emphasis was placed on whether spontaneous or induced seizures (position, head movement, upright, vision, sound, Valsalva movements) were emphasized when conducting vertigo/dizziness consultations; At the same time, the application of
concepts such as positional and orthostatic is clarified.
The corresponding concepts
of positioning and postural are abandoned.
3.
Emphasize that attention should be paid to vestibulo-visual symptoms
.
These symptoms are caused by lesions of the vestibular system or by visual interaction with the vestibular system
.
These include false sense of movement, visual tilt, and visual distortion (blurring) due to loss of vestibular function rather than vision
.
Clinically, these symptoms are often overlooked
.
(a) external vertigo, no longer using visual vertigo; (b) oscillopsia (bidirectional reciprocating visual movement); (c) visual delay; (da) visual oblique; (e) Blurred
motor vision.

4.
Postural balance related only to vestibular is defined as postural symptoms
.
(a) Posture instability in sitting and walking: uniformly defined as unsteadiness, while the old terms disequilibrium and imbalance are no longer used; (b) fall episodes, otolithiccrisis, Tumarkin crisis (Tumarkincrisis) terms are no longer used, Uniformity is defined as balance-related nearfalls or balance-related falls
.

(2) The main points
of differential diagnosis without differential diagnosis of consultation, there is no diagnosis!

1.
Acute persistent vestibular syndrome

➤ Typical consultation is easy: differential diagnosis
of inflammation such as VN, vascular disease such as IS, poisoning, etc.

➤ Such as dorsovensolateral syndrome (Wallenberg syndrome) (1)
true bulbar palsy on the sick side; (2) Pain and temperature loss of facial pain on the sick side (damage to the spinal tract nucleus); (3) cerebellar symptoms on the sick side (damage to the lower foot of the cerebellum); (4) Pain and temperature loss of contralateral limb (damage to the myelothalamic tract); (5) nystagmus and vertigo (damage to the vestibular nucleus); (6) Horner's sign (damage to sympathetic nerve structures).

➤ Attention to the consultation of AVS (1) Positioning consultation: for acute persistent vertigo/dizziness, the focus of the consultation is to identify central/peripheral problems, that is, the examination of central-related symptomatology - hemianopia, ataxia, diplopia and other neurological symptoms; Considering that 80% of the central causes are related to vascular disease, if you encounter patients with advanced age or severe arteriosclerosis, pay attention to timely central MRI examination
.
(2) Etiology consultation: focus on vascular diseases, immunoinflammation, trauma, poisoning and other factors
.
(3) Differential consultation: PICA and AICA regional PCI (more common in the elderly, often accompanied by a history of arteriosclerosis/sudden deafness, differentiated from VN and labyrinth stroke), labyrinthine stroke (differentiated from VN and AICA-PCI), VN (history of viral infection or ear pain, differential autoimmune inner ear disease/labyrinthine stroke/central isolated PCI), attack period of VM - continuous dizziness and vertigo (more common in youth, no arteriosclerosis, with a history of migraine), Acute UPVD compensatory status (clinically often resembling EVS, attention to recognition).

➤ Atypical AVS consultation focuses on arteriosclerosis factors and follow-up! A.
Differential diagnosis of solitary central vertigo: central: such as cerebellar stroke? Peripheral: such as UPVD labyrinthine - vestibular branch stroke? VN？ B.
Central vertigo + hearing loss differential diagnosis center: such as brainstem stroke? Peripheral: such as UVL+ audiologically impaired labyrinth main branch stroke? MD? C.
PCI differential diagnostic center with delayed DWI development: such as brainstem, cerebellar stroke? Peripheral: e.
g.
UVL ± audiology impaired? Lost in a stroke? VN? MD? D.
Differential diagnosis center of EVS acute attack: VM peripheral: MD 2.
Typical diagnosis of episodic vestibular syndrome: BPPV/TIA/EA, etc.
; ➤Clinical manifestations of TIA: dizziness, balance disorders, may be accompanied by tinnitus; Associated characteristic symptoms and signs: impaired consciousness with or without miosis; Extraocular muscle paralysis and diplopia; numbness or cross-cutting sensory disturbances on one or both sides, perioral areas; dysphagia, dysarthria; Ataxia; Cross-cutting paralysis: oculomotor nerve cross-palsy, facial abduction nerve cross-palsy; Fall seizures; Cortical blindness; Transient global amnesia
.
Differentiates associated episodic lesions: focal EP, Meniere's disease, migraine
.
➤ Attention to the consultation of EVS: (1) Induction of seizure examination: position (BPPV, light crest cap, VP, CPPV including VM), head movement (VM, PPPD), upright (MSA, hemodynamics, etc.
), vision (VM, PPPD), voice or Valsalva action (superior semicircular fissure, external lymphatic fistula), Other triggers such as stress – very helpful in the diagnosis
of etiology.
(2) Spontaneous onset consultation: UPVD, MD, VP, TIA, EA2, VM.

(3) Recurrent isolated vertigo: patients with seizures are difficult to diagnose, and multi-dimensional evaluation and rediagnosis
during seizures are required.
(4) Note that many times EVS visits are actually compensatory manifestations of AVS; Patients with BPPV sometimes have inadequate symptom expression; MD/sudden deafness/self-exempt/VM/acoustic neuroma can all be accompanied by hearing loss; EA diagnosis notes family history problems
.
3.
Chronic vestibular syndrome (1) Persistent postural-perceptual dizziness consultation: (PPPD) :(a) Deep understanding of the connotation of diagnostic criteria: persistent, perceptual dizziness, instability, non-rotational vertigo≥ 3 months; (b) Aggravating factors are the core: chronic vestibular cortex dysfunction is re-"adapted" poorly - for posture, movement, Poor visual processing; (c) Difficulties in interviewing: PPPD and other chronic vestibular syndromes (chronic unilateral and bilateral vestibular lesions); Persistent dizziness from non-vestibular systems such as chronic medical diseases needs to be differentiated, and the core of differentiation from early neurodegenerative diseases ---- the problem of visual-vestibular interaction
.
(2) Examination of chronic unilateral and bilateral vestibular lesions (primary and secondary): (a) pay attention to dizziness, visual symptoms, instability, cognitive and spatial impairment symptom cues; (b) pay attention to acute, secondary, and drug factors
.
(3) Central genetic/degenerative lesion consultation: often need to combine the first symptoms, pathophysiological characteristics, positioning involves multi-system problems, the cause involves genetics, degenerative factors, early and PPPD and other chronic dizziness is not easy to identify, high requirements for doctors
.

4.
Consultation case reviews

Case 1: Core symptom concept (chief complaint)? Concomitant symptoms? It is not clear (1) the question of acute vestibular syndrome
.
(2) Differential diagnosis: AICA regional lesions, labyrinthine stroke/sudden deafness with vertigo, MD, autoimmune internal ear disease and labyrinthitis
.

Differential examination
of acute peripheral labyrinth (cochlea + otolithiasis + semicircular canal damage) and central (cerebellum, brainstem symptomatology).

Case 2: Core symptom concept (chief complaint)? Concomitant symptoms? What is the dynamics of diagnosis and treatment? It is not clear (1) episodic vestibular syndrome - positional nystagmus question
.
No.
13 left horizontal tube bppv, this time left posterior BPPV; But sn to the left? Refuse double temperature
.
(2) Differential diagnosis: MD - no hearing, VM - no headache & single type of vertigo, autoimmune internal ear disease - no self-immunity & spontaneous vertigo; VP, TIA, and cardiogenicity do not appear to be supported
.

Possible BPPV is recommended to improve SVV, OTR, VEMP, dual temperature and swivel chairs, and cerebral perfusion evaluation
if necessary.

Case 3: Onset of the disease? Diagnosis and treatment dynamic?-- examination retrospective and perfect medical history--restore the scene? It is not clear (1) the question of acute vestibular syndrome as opposed to episodic vestibular syndrome

(2) Restore the scene of the onset by the onset of the disease; Dynamic diagnosis and treatment dynamics + examination retrospective to improve the medical history suggest that in fact one side of the labyrinth is extensively damaged, rather than simple BPPV.

Case 4: Diagnosis and treatment dynamics? --- attention is not clear about the evolution of the disease (1) The diagnosis of chronic complications of episodic vestibular syndrome BPPV, rather than BPPV itself
.

(2) Restore the site of onset - BPPV by onset; Dynamic diagnosis and treatment dynamic + examination - BPPV residual symptom problem? Distinguish dizziness? Functional factors are involved in the occurrence of
PPPD.

Case 5: In addition to the chief complaint + current medical history consultation, basic medical history?-- past history/personal history/family history, etc.
are also very important (1) Acute vestibular syndrome consultation; Surely cerebrovascular disease – problems associated with dizziness? Dizziness diagnostic problem? (2) Through the basic medical history: suggests an immune-mediated mechanism—vasculitis/demyelination
.

If the current medical history is further described through the diagnosis and treatment information, it is more helpful to clarify the comorbidity of central and peripheral damage of dizziness or simple central damage? Do you have dizziness? Functional factors are involved in the pathogenesis of PPPD
.

Summary & prospect 1.
The conceptual mastery of vestibular symptom classification in ICVD is the basis; 2.
The main points of disease diagnosis criteria are the core content of consultation; 3.
Consultation without differential diagnosis is a consultation without connotation; 4.
The acquisition of dynamic information of diagnosis and treatment is an important guarantee for the optimization of consultation; 5.
The study of symptomatology/consultation is conducive to the improvement and formulation
of diagnostic standards for related diseases.

This article is an English version of an article which is originally in the Chinese language on echemi.com and is provided for information purposes only. This website makes no representation or warranty of any kind, either expressed or implied, as to the accuracy, completeness ownership or reliability of the article or any translations thereof. If you have any concerns or complaints relating to the article, please send an email, providing a detailed description of the concern or complaint, to service@echemi.com. A staff member will contact you within 5 working days. Once verified, infringing content will be removed immediately.