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Ростовский Государственный Медицинский Университет
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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_186_библиотеки_им_акад_М_И_Перельмана

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ThemostcommonpersistentsymptominpatientswithPCSisheadacheandshouldbetreatedmoreor lessasanyotherheadache(seepage118fordetailsonpost-traumaticheadache).Forpatientswith persistentdizziness,vestibularrehabilitationmaybebeneficial.Othersymptomssuchasdepressionand anxietyshouldbeaddressedintheusualmanner.Persistentmentalsluggishnessanddisruptedsleep usuallyslowlyresolveontheirownoverweekstomonths.
Themajorcomplicationsofpostconcussionsyndrome(PCS).
MostpatientswithPCSrecoverwithinseveralmonths,butasmanyasone-thirdmayhavesymptoms thatpersistformuchlonger.Thereisnoknowninterventionthatcanspeedtheirrecovery.
https://t.me/med1917
ChronicTraumaticEncephalopathy
Thisdevastatingsyndromeappearsinpatientsaftermultiplerepetitiveconcussions.Athletesandmilitary personnelarethemostlikelytobeaffected.Symptoms,whichcanincludedepression,anxiety,mental sluggishness,and/oralterationsinpersonality,canbesubtleatfirst,butovertimebecomemore pronounced.Suicidalideation,violence,andaggressionareoftenthemostobviousmanifestationsofthe patient’semotionaldysregulation.Motordisturbancesincludeataxia,tremor,parkinsoniansymptoms,and motorneurondisease(amyotrophiclateralsclerosis).Symptomsofdementiacanappearandprogress rapidly.
Thepreciseincidenceofchronictraumaticencephalopathy(CTE)isnotknown.Itappearsthatoneor twoconcussionsmaynotincreasetherisk,butthreeormoreprobablydo(itisunlikelythisisahardand fastrule,butitisausefulapproximationofrisk).Thus,thetotalnumberofheadimpacts,nottheir severity,maybethebestprognosticator.Manyyoungfootballplayerssustainthousandsofheadimpacts beforetheirplayingdaysareover.Patientswithmorethantwoconcussionsshould,ifatallpossible,not resumetheircontactsport(orreturntomilitaryactivitythatputsthematrisk)eveniftheirrecoveryfrom eacheventhasbeentotal.
CTEcanonlybediagnoseddefinitivelyatautopsy.Thekeyfindingistheaccumulationoftauproteinin thebrainparenchyma.
ComparisonofanormalbrainandaCTEbrainatautopsy.
ThereisnoknowntreatmentforCTE.
https://t.me/med1917
Follow-uponYourPatient:Youdon’thavetobealicensedneurologisttoknowthatPaul
shouldnotreturntoplaytoday.Foranathleteengagedinanon-contactsportwhoisfully recovered,returncouldbeconsidered.Paul,however,isafootballplayerandisnot completelyasymptomatic.Mostexpertswouldrecommendaperiodof“brainrest,”andthat henotreturntocontactsportsforatleast10days,andthenonlyifheremains asymptomaticfollowingagradualreturntofullactivityprotocol.
Younowknow:
1. Theredflagsthatnecessitateurgentevaluationfollowingheadtrauma
2. HowtodetermineifapatientwithmildheadtraumarequiresaCT
3. Howtorecognizeandmanagethemostcommonsymptomsofconcussion
4. Theusualarcofrecoveryfollowingmildtraumaticbraininjury
5. Howtodiagnoseandmanagepostconcussionsyndrome
6. Howtoperformasidelineevaluationofathletessufferingheadtrauma,andhowtoguidetheirrecoveryandreturntoaction
7. Theriskfactorsandoftendevastatingmanifestationsofchronictraumaticencephalopathy
1
Someguidelinesareabitmoreforgiving,allowingverylightactivityearlieriftheathlete’ssymptomsaremildandimproving.
https://t.me/med1917
5Dizziness
Inthischapter,youwilllearn:
1. Whatpatientsmeanwhentheytalkaboutdizziness
2. Allaboutvertigo:whatitis,whentoworry,andhowtotreatit
3. How to perform the HINTS exam, which will help you distinguish central from peripheral vertigo
4. Howtothinkaboutsyncopefromaneurologist’spointofview
CASE5
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YourPatient:Kyle,a64-year-oldlawyerwithahistoryofhypertensionandcoronaryartery
disease,presentstotheemergencydepartmentwithsudden-onsetvertigo.Hestatesthat
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hewasinhisusualstateofhealthuntilapproximately2daysagowhenhebegantofeel dizzyandoff-balance.Heinitiallyattributedthesesymptomstoexhaustion—he’dbeen workinghardonacaseandhadn’thadmuchtimetoeatorsleep—butbecameworriedafter hefellthismorningongettingoutofbed.Whenyouaskhimwhathemeansby“dizzy,”he tellsyouthathefeelsasthoughtheworldisspinningaroundhim.Thesensationhas significantlyimprovedoverthepast24hours,buthestillfeelsunsteadyonhisfeet.Healso tellsyouthathehashad“abitofaheadache”andthinkshislefthandisweak;hehad troubleusingittobuttonhisshirtthismorning.Onexamination,youthinkyoudetectafew beatsofverticalnystagmuswhenyouaskhimtolookuptotheceiling,butit’shardtotell becausehekeepsclosinghiseyeswhiletellingyouthatyourexaminationismakinghim dizzyagain.Hislefthandisfullstrengthbutdysmetriconfinger-nose-fingertesting.His examinationisotherwisenormal.What’sthenextstepinyourmanagement?
Dizzinessisoneofthemostcommoncomplaintsencounterednotonlybyneurologistsbutbyemergency cliniciansandprimaryhealthcareprovidersaswell.Itisalsoahighlynonspecificsymptom.Dizziness canbetheresultofanunderlyingneurologicdiseasebutcanalsobeindicativeofcardiacdisease,an electrolytederangement,anemia,infection,andanxiety.Mostofthetimedizzinessisbenign,someofthe timedisablingand—fortunatelyfarlessoften—life-threatening.Howdoyoutellthedifference?That’s whatwe’reherefor.
ASimpleWaytoCategorizeDizziness
Whatdopatientsmeanwhentheycomplainofacutedizziness?Despitethemanydifferentwaysof describingthesensation,therearereallyonlytwooptions:
1.  Lightheadedness. This is the feeling that you might faint. Some patients will report actual fainting (the formal term for this is syncope),and describe lightheadedness as theimmediatesensationbefore losingconsciousness;otherswon’tactuallysyncopize but willreportfeelingasthoughtheymight(presyncope).Lightheadedness isincredibly commonand mostoftenbenign.Thatsaid,if the sensation isbothersomeenough to bringa patient intothe officeor theemergencydepartment, or if theyhave actuallyexperienced syncopeorpresyncope,itmustbetakenseriously.
2.  Vertigo. Mostpeople thinkof vertigoas a spinningsensation, butthat’snot alwaystrue. Thebetter definitionof vertigo is thefalse sensationofmovementor,toputitmoresimply,thesensationofmovementwhennothingisactuallymoving.Thatsensationmaybe oneofspinning—eitheryouyourselfortheworldaroundyou—butitcanalsobeafeelingofrockingback-and-forthorside-to-side,or evenamorevagueoff-balance,off-kiltersensation.
Whenpatientscometoyoucomplainingofacutedizziness,thedistinctionbetweenlightheadednessand vertigoisthefirstandmostimportantthingyoumustdetermine,becauseitwilldrasticallyalteryour diagnosticworkupandmanagement.Ifpossible,don’taskyourpatientspecificallyaboutaspinningor lightheadedsensation.Bevague;youdon’twanttoputwordsintoyourpatients’mouths.‘Whatdoyou meanbydizziness?’isagoodplacetostart.Trytogiveyourpatientstheopportunitytothinkaboutwhat they’reactuallyexperiencing.Youmightbesurprisedbyhowhelpfultheirownwordscanbeinleading youintherightdirection.
Box5.1
https://t.me/med1917
Somepatients,particularlytheelderly,mayexperienceunsteadinessorimbalancewhen walkingorstanding,anddescribethesensationasoneofdizziness.Thisfeelingisreferred toasdisequilibriumandisbestthoughtofasachronicformofdizziness.Manyfactorscan contributetothisfeeling:diminishedproprioception,impairedgait,weakness,deconditioning, andevenauditoryorvisualproblems.Itisimportanttodistinguishdisequilibriumfromactual dizzinessbecausethetherapeuticapproachesaredifferent.Treatmentofdisequilibrium shouldbedirectedatspecificcorrectivemeasuressuchashearingaids,newglasses, canes,walkers,orphysicaltherapy.
Vertigo:AnOverview
Anatomy
Vertigoisasymptom,notadiagnosis.Itcanbetheresultofadisorderofeitherthecentralorperipheral nervoussystem.Thedifferentialdiagnosisandprognosisareverydifferentforthesetwoanatomic categories.Tohelpyoumakesenseofthisdistinction,aquickreviewofthevestibularsystemis necessary.
Thevestibularsystemisthesensorysystemthat’sresponsibleforthedetectionofmotion,head position,andspatialorientation.Theneurologicpathwaystartsintheinnerear,whichcontainsthe cochlea(responsibleforsoundtransduction)andthevestibularlabyrinth.Thevestibularlabyrinth containstwoimportantstructures:
1.  The semicircular canals. These are three tiny, fluid-filled tubes positioned at right angles to one other. They sense angular acceleration.Whentheheadis rotated,thefluid(endolymph) withinthecanalthatis situatedintheplaneofmovementflowsinto an expansionofthecanal,calledthe ampulla. Theampulla containshair cells,whichare thesensoryreceptorsofthevestibular system. Movementofstereociliaattachedtothesehaircellsresultsinthereleaseofneurotransmittersthatrelaythisinformationtothebrain.
2. Theotolithorgans(utricleandsaccule).Thesedetectlinearacceleration,thatis,movingforwards,backwards,andupanddown. Theutricledetectsmovementin the horizontal plane,andthesacculedetectsmovementinthevertical plane.Thesealsocontainhair cells, which sense movement when gravity-sensing crystals of calcium carbonate (called otoconia), which rest upon a gelatinous membranethatoverliesthehaircells,shiftinresponsetomotion.
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(A)Thestructuresoftheinnerear.Youcanseethatthevestibularlabyrinthiscomposedofthe semicircularcanalsandotolithorgans.(B)Thehaircellsandotoconiawithintheotolithorgans.
Thevestibularportionoftheeighthcranialnervereceivesinputfromthehaircellsandthenentersthe brainstemtoterminateonthevestibularnuclei.Thesenucleisendprojectionstotheoculomotorcranial nervenuclei(CN3,CN4,CN6),cerebellum,andspinalcord,amongothertargets.Vestibulo-ocular connectionsareresponsibleforstabilizationandcoordinationofeyemovementsduringheadmotion;
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vestibulospinalpathwayshelpmaintainposturalequilibriumandbalance;cerebellarconnections modulatetheseactivities.
Theneurologicpathwaysfromthevestibularlabyrinthintothebrainstem.
Themostimportanttakeawayhereisthedivisionbetweenperipheralandcentralvertigo.Whenwetalk aboutperipheralvertigo,wemeanvertigocausedbydysfunctionwithintheinnerearoraprocess affectingCN8beforeitentersthebrainstem.Centralvertigoisduetopathologywithinthecentral nervoussystemitself,typicallyaffectingeitherthebrainstemorthecerebellum.Centralvertigofrom hemorrhageorinfarctionintheposteriorfossacanbelife-threatening.
PeripheralVersusCentralVertigo
Sohowdowedistinguishperipheralfromcentralvertigo?Clinically,peripheralandcentralvertigohave distinctbutoverlappingfeatures.Mostofthetime,yourhistorywillgiveyoutheanswer(benign paroxysmalpositionalvertigo[BPPV],forinstance,isacommoncauseofperipheralvertigoandis typicallyrelativelystraightforwardtodiagnosejustfromthepatients’descriptionsoftheirsymptoms;see page144).Butsometimes,thestoryisn’tsoclear.Aswe’vealreadynoted,dizzinesscanbehardto describe.Yourneurologicexaminationcanhelp,too.
TheHINTSexam(forHeadImpulsetest,Nystagmus,TestofSkew)isascreeningtoolthatcanhelp distinguishbetweencentralandperipheralvertigo.Ithasthreecomponents:
1. HeadImpulseTest.Thisisatestofthevestibulo-ocular reflex (VOR;see Box5.2).Holdthepatient’sheadinyourhandsand ask
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them tofixatetheirgazeonyournose.Slowlyrotatethepatient’s headside tosideandthen, abruptly butgently,accelerate thehead backtoneutralposition.IftheVORisintact,thepatientwillbeabletomaintaingazefixationonyournose.Ifnot,youwillseeaquick corrective saccade (meaning a rapideyemovementthatquickly alters thepointoffixation)as the eyes “catchup”tothe headand quickly re-fixate on your nose. The VOR is a peripherally mediated reflex involving the eighth, sixth, and third cranial nerves (remember, thecranialnerves apart from CN1 andCN2 are part ofthe peripheral nervous system). Therefore, in the appropriate clinicalcontext,thatis,inapatientwithongoingvertigo:
Apositivetest(thepre sence ofa cor rec tivesac cade ,indicatingady sf unctionalVOR)issuggestiveof aper iphera llesion.
Anega tivetest(thea bsence ofa sacc ade )is,by def ault,indicativeofa ce ntrallesion.
Howtodoaheadimpulsetest.
2. Nystagmus.Nystagmusisaninvoluntarybiphasicoscillationoftheeyes characterizedbyafastphaseinonedirectionfollowedbya slowphaseintheother.Nystagmuscanbehorizontal(right-orleft-beating),vertical(down-orup-beating),torsional,ormixed.
Ny stagm usdue toperipherallesions tendsto be either hor izontalor horizontal/torsional,notpur ely  torsionalor ve rtica l.It isunidirec tional( e.g., the fa stpha se alwa y sbe ats toward the lef tor towa rd the rightr ega rdless of the direc tionofgaze),suppre ssedby visualfixa tion(e.g.,whe nfixatingonastaticobj ec t),a ndoftenm ostprom inentonend-ga ze(e .g.,theam plitudeincre ase swhenlookingtothe extre me leftor right).
Ny stagm usduetoce ntrallesionsisof tenve rtical,m ultidirectional(e .g.,right-bea tingonrightgaze,left-be atingonleftga ze),anddoe snotsuppresswithvisualfixation.
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