《头晕》视频文字版.docx

头晕视频文字版（该视频中dizziness“头晕”实际指眩晕）Dizziness by Dr. Ashley StrobelObjectives目标Focused History（显著病史）、Physical Exam（体格检查）、Benign VS Emergent （良性VS急性）、When to Image（何时行影像学检查）、Treatment（处理）Benign VS Emergent 良性VS急性NOT central VS peripheraltoo complex现已不再区分中枢性及外周性，因其太复杂。Ischemic posterior CVA or bleed is the emergency!后循环缺血性卒中或出血是急性的。While 25% of CVA presents with dizziness, only 3.2% of dizziness ED visits are for CVA/TIA虽有25%的卒中患者出现头晕，仅3.2%头晕急诊患者被诊为卒中/短暂性脑缺血发作。Peripheral Pathophysiology 外周病理生理Labyrinth and CN 8 迷路与第对脑神经Labyrinth: 3 semicircular canals and otoliths: uticle and saccule 迷路：三个半规管及含有耳石的椭圆囊和球囊。Impulses from labyrinth travel to CN 8(vestibular and cochlear nerves) 冲动由迷路传入第对脑神经（前庭蜗神经）Central Pathophysiology 中枢病理生理Brainstem脑干：vestibular nuclei in medulla and pons 延髓和脑桥之前庭神经核Cerebellum小脑（因其处密闭空间，须觅良法查之）Other contributing factors to dizziness其他对头晕起作用之因素Spinal cord impulses脊神经冲动（后角感觉外周感觉）Occipital lobe impulses枕叶冲动（视觉相关）Dizziness Definition 头晕分类Vertigo=Acute Vestibular Syndrome 眩晕=急性前庭综合征Vertigo: motion, disorientation in space 眩晕：动性或位置性错觉Presyncope: diaphoresis, about to faint or pass out, seeing stars昏厥前期表现：出汗，欲倒，眼冒金星Disequilibrium: difficulty standing upright, assoc with periph neuopathy前兆：难以直立，（没有摔倒而感觉可能摔倒，恶心），伴随有外周神经病。Weakness: organic, fatigue/tired虚弱状态：可为器官性，疲乏/劳累History: Deadly DsDiplopia 复视Dysarthria 构音障碍Dysphasia 言语障碍Dysphonia 发声困难Dysaesthesia 感觉不良Drop attacks without syncope 无昏厥的摔倒发作Down-is-up distortions (room tilting) 上下颠倒式感觉失真（房间倾斜）（如有上述症状，需要治疗）Acute Vestibular Syndrome: When to worry?急性前庭症状：何时予以关切？Multiple prodromal episodes 多次前驱症状发作（患者自觉即将发生眩晕）Abrupt onset while awake 醒时突然发作Disproportionate vomiting or gait disturbance 异常的呕吐或步态障碍Headache or neck pain 头痛或颈痛Acute new hearing loss (except Menieres) 急性新发听觉丧失（除外梅尼埃病）New neurologic symptoms 新发神经症状History for Acute Vestibular Syndrome急性前庭症状病史“Describe to me how you feel without using the word dizzy”“除了使用头晕一词，来描述一下你的感觉”Dizzy in spells? 头晕间断性发作？（一过性/持续性）Triggers? 触发的原因？（站立/卧位/注视）Timing? 时间？（何时开始/何时消失）HINTS exam better than MRI?HINTS检查法优于MRI？Diagnosis of ischemic posterior fossa stroke缺血性后颅窝卒中的诊断MRI/DWI sensitivity 100% at 72 hrs but not priorMRI（弥散）/DWI敏感度可达100%，但要在72小时以后出结果。HINTS Exam HINTS检查法ead mpulse (specific, NOT sensitive)HI：甩头试验（有特异性，不敏感）（受试者坐，头前倾30，测试者面之，双手定其头，嘱其双眼前视测试者鼻。测试者以连续、骤然、尽可能快之速度甩其头部向两侧，角度约1530，尽可能使之无法预测甩动方向及开始时间。甩动停止后观察其眼震情况。如能聚焦于视靶则为阴性，如前庭-眼动反射异常，则眼球“甩至头同侧”，其后再主动向回扫视重新盯住鼻尖，则为阳性。重者可呕吐。）ystagmus (good sensitivity)N：眼震试验（敏感性好）（如果说水平震颤还可接受，则垂直震颤都是恶性的）est of kew (good sensitivity)TS：倾斜试验（敏感性好）（先嘱其以手遮一目，视鼻，移手，如前所遮目偏斜，则阳性，复测另一目）Add hearing to decrease near misses为减少误差可行听力测试（如无音叉等专业工具可采用两耳边搓手指辨是否不同之法）Sensitivity 100%, specificity 96% for a central lesion if 1 of 3 to positive若三者之一为阳性，可认为有中枢神经系统损伤，敏感性100%，特异性96%HINTS: Look for INFARCT findingsHINTS：寻找梗死迹象（INFARCT）mpulse ormal in the setting of vertigo = BADIN：存在眩晕的情况下甩头试验却正常=不好（内耳有问题/中风）lternating fast phase nystagmus (bidirectional) = BADA：交替快相眼震（双向）=不好（双向可能有中风/垂直震颤亦属不好）efixation on over est (refixation = vertigo adjustment) = BADRCT：倾斜试验中遮住眼时向上偏斜=不好HINTS = INFARCT chartHINTS法排除卒中表Impulse TestNystagmusSkewDIAGNOSISAbnormal阳性Unidirectional单向Absent无Neuritis神经炎Abnormal阳性Unidirectional单向Present有Stroke中风？Abnormal阳性Bidirectional双向Absent无Stroke中风？Abnormal阳性Bidirectional双向Present有Stroke中风？Normal阴性Unidirectional单向Absent无Stroke中风？Normal阴性Unidirectional单向Present有Stroke中风？Normal阴性Bidirectional双向Absent无Stroke中风？Normal阴性Bidirectional双向Present有Stroke中风？注意：1.只有第一种情况下情况不属紧急，其他都不安全。 2.为何三结果分别为“阴性、单向、有”仍不安全？因其在眩晕情况下行此三试验，故可怀疑其为迷路炎/前庭炎，高血压/血管病，并且排除中风。 3.此表实为一可能性向前积分系统，非确诊用，Stroke非谓其必为中风，仅指此时需留观以排除卒中。Peripheral Vertigo Must-Haves 周围性眩晕之必要条件Unidirectional nystagmus 眼震方向不确定Abnormal Head Impulse Test 甩头试验阳性Normal test of Skew 倾斜试验正常Nystagmus 眼震VERTICAL is ALWAYS bad 垂直眼震必定为不好的情况Nystagmus is the fast direction, and the lesion is opposite the fast saccade眼震为快相，损伤在快速扫视出现的对侧Central: bidirectional or vertical 核心：注意双向的（可出现于大仑丁中毒，然仍需排除卒中）和垂直的Romberg闭目难立征Romberg positive = peripheral lesion Romberg征阳性=周围性损害（？）What is Positive? 何为阳性？ Fall to one side when they close their eyes 闭目倒向一侧Gait 步态Walk every patient. PERIOD 先要让每位患者行走。If they are unsteady they cant go home. 如果为蹒跚行走，则不能让其回家。Imaging? 影像？CT for vertigo = Low 0 2.2% yield 检查眩晕使用CT：置信域低至02.2%Skip the CT and go for MRI/MRA if the patient cant stand and you are concerned for central lesion like vertebrobasilar insufficiency若患者难以站立，且疑为椎-基底动脉供血不足等中枢性损伤，跳过CT，直接做MRI/MRA。（椎-基底动脉供血不足的概念多已不用）Not a stroke, then what? 不是卒中，是什么？Neck Pain + dizzy + recent trauma/manipulationVertebral artery dissection颈痛+头晕+近期有外伤（如车祸）椎动脉夹层Have a CN deficit or ataxia associated可能有中枢神经系统灌注不足（后循环缺血）或共济失调相关Dx: CTA or MRA 此时进行影像检查：CTA/MRAEpisodic and Positional 发作性或位置性（比如一个22岁的青年人，中风几率很小）BPPV良性阵发性位置性眩晕（HINTS：甩头不正常，无眼震，倾斜试验阴性；Romberg征阴性；只出现“不愿意动”内耳有病毒感染或BPPV，Dix Hallpike试验区别之）PE: normal neuro, no hearing deficit, nystagmus should be mixed, upbeat/torsionalPE：神经正常，无听力损伤，眼震为混合性、上升或旋转Dx: Dix Hallpike 此时做Dix Hallpike试验Dix HallpikeHead 45 to right 头右转45（左转亦可）Lay Patient back flat from sitting 让患者由坐位躺下为仰卧姿势Have the patient open their eyes and eyes beat TOWARD the downward ear for BPPV让患者睁眼，如见眼震向下，则为BPPVEpley Maneuver Epley复位法Dix Hallpike 先做Dix Hallpike步骤Turn head the other way 将头转向另一侧Roll patient onto the side with the head downward 让患者侧躺向头刚刚转过去的方向Sit them up 坐起（相当于让耳石绕了一圈，如效果不好可多试几次）Treatment Benign Causes 良性病变的治疗BPPV:Epley maneuver （如果患者感到恶心不要做Epley复位法）If dont tolerate: antihistamines (promethazine 6.25 mg IV, meclizine), anticholingergics, antidopaminergics, and GABAergic drugs (lorazepam)如不能忍受：抗组胺药普鲁米近（非那根）6.25mg iv/美其敏，抗胆碱药，抗多巴胺药和GABA能药物（劳拉西泮）。Ondansetron ineffective可用昂丹司琼控制恶心，但对此病不太有效Recent viral illness + 如近期有病毒感染Labrynthitis : hearing loss + vertigo INFARCT negative迷路炎：听力损失+眩晕INFARCT测试阴性Vestibular neuritis: no hearing change + vertigo INFARCT negative (steroids have no utility)前庭神经炎：无听力变化+眩晕INFARCT测试阴性（类固醇无效）（告诉患者：“可能会加重，但时间会治疗一切。”）Episodic Spontaneous 类似的发作性疾病Vestibular Migraine, Menieres, TIA or arrhythmia, Hypoglycemia Add hearing loss/tinnit