There are many different diseases that cause vertigo, some are neurological and some are otologic. It is really difficult to clarify the cause of many vertigo cases; otology does not consider it to be otogenic and neurology cannot find the cause, so it is not easy to give a clear statement to the patient.
There are many diagnoses of insufficient blood supply to the basilar artery, why? My feeling: one is that the incidence of the disease is really high in the elderly; the other is that no other cause can be found, and besides, the diagnosis of the disease is not prone to dangerous consequences.
Is vertigo in the elderly a deficiency of blood supply to the vertebrobasilar artery?
Other causes of vertigo are: inner ear vertigo, intracranial tumor vertigo, brain infection or vestibular neuronitis vertigo, drug-induced vertigo, multiple sclerosis, fourth ventricular cysticercosis, head and neck trauma, internal otolith syndrome, epilepsy (vertiginous), functional vertigo, etc. In patients with vertigo, it should be clarified only after a detailed history and examination.
Also in elderly patients.
1, vertigo occurs when getting up or when turning the head, and it can be relieved in a few tens of seconds or after the head position is corrected: it should be more likely to be cervical vertigo or inner ear otolithiasis.
2, vertigo all day long, can also vomit, can last for a month or several months: intracranial tumor vertigo, posterior circulation ischemic vertigo, demyelinating vertigo should be considered.
3. Having a cold a week ago, severe vertigo at the onset: with a history of infection, infectious vertigo of the brain, vestibular neuronitis, and epidemic vertigo should be considered more often.
4.Sighting in pairs and swallowing disorder appeared, which was relieved after 5 minutes: Consider TIA of conus basalis artery system as a high possibility.
5. Vertigo with tinnitus and history of hearing loss: vagal stroke, inner ear vertigo, auditory neuroma, drug toxicity are all possible.
The above diagnosis is only possible, but there are also detailed examinations on the patient, such as vestibular function test, MRI, nystagmography, transcranial Doppler ultrasound, brain evoked potentials, EEG, DSA, etc.
The reason why I posted this post is that I found that many doctors do not pay attention to vertigo, and a lot of medical care is wasted, but there is no need for infusion.
I don’t agree with the vague diagnosis of insufficient blood supply to the vertebrobasilar artery, because it is not yet TIA, and in fact the percentage of vertigo accounted for by vertebrobasilar TIA is very small.
But 2 belong to chronic vertigo: it is caused by the gradual degeneration of the vestibular system in the elderly, and the symptoms persist until a new balance is reached. Treatment is short-term anti-vertigo treatment such as oral medication , fenagan injections etc. can be used in the acute phase, but not in the long term, as it can prevent the establishment of a new balance. Thereafter, the patient should be exercised to walk along a straight line.
Benign positional vertigo should be treated with rehabilitation exercises in different brain positions.
Anterior auditory neuronitis is less clinically diagnosed and is mixed into the vertebrobasilar artery insufficiency of blood supply.
In 1990’s Neurology, some scholars jokingly called neurology as a difficult garbage can. You neurology colleagues should be proud that Vertigo is essentially a motor hallucination – but unlike psychiatric symptoms, dizziness is the feeling of dizziness. There is no confusion between the verbiage of the people and the academic vocabulary (both Chinese and English, ordinary dictionaries don’t count), but of course the current part of neurology has a sense of playing with words, that is, it lacks the charm of straightforward clinical practice.
VBI has a tendency to stop being used – there has been a death sentence. The concept of chronic cerebral insufficiency has been mentioned by the Japanese Ministry of Health and Welfare, but is not widely recognized. I feel that there is a change of concept and sometimes there is a suspicion of overkill.
It is thought that the cause of vertigo in the elderly is mainly benign positional vertigo and positional sensory abnormalities, that is to say, most of the patients have to be referred to the pentacam. I very much hope that someone in China will seriously do scientific research on such etiology and diagnostic norms and give us a statement so that I can learn to imitate it. There is a foreign SCI journal for Gait (Disturbance), indeed there is a lot of work to do.
Is the concept of “inadequate blood supply to the basilar artery” still useful?
Vertebrobasilar insufficiency (VBI) describes a wide range of clinical manifestations caused by the common pathophysiological process of reduced blood supply to the brain from the posterior circulation. VBI was widely used. Although the obscure concept of “carotid insufficiency” is no longer used, VBI is still used to cover all TIAs of the posterior circulation.
The brainstem is an important site of neurological activity, with cranial nerves, reticular activation system and up and down motor-sensory nerve bundles in a small space. vertigo, visual changes (loss of vision, diplopia or nystagmus), and limb weakness.
The diagnosis of VBI requires revealing CT, MRI, and MRA. Recent developments in neuroimaging have led to a new understanding of the prevalence of VBI, and some studies have reported that about 40% of people with VBI have brainstem infarction. Therefore, the concept of VBI has been applied less and less and has been replaced by the concept of “posterior circulation ischaemia” (PCI).
However, VBI is still widely used in neurology, general medicine, internal medicine, geriatrics, Chinese medicine, and orthopedics in China, and is most often used to diagnose simple dizziness/vertigo in the middle-aged and elderly population with imaging evidence of cervical spine osteophytes. The theoretical hypothesis for the diagnosis is that the osteophytes cause an inadequate blood supply to the vertebral basilar artery, which results in abnormal function of the ischemia-sensitive vestibular nucleus and consequently produces dizziness/vertigo (as the name implies, inadequate blood supply rather than ischemia). Many physicians fail to take a detailed history and perform a careful neurological examination, and incorrectly assume that the primary cause of simple dizziness/vertigo in the middle-aged and elderly is a VBI rather than a periventricular lesion or psychiatric disorder. To make matters worse, patients diagnosed with VBI are not screened for aggressive vascular risk factors and their treatment does not follow scientific evidence (control of vascular risk factors, aspirin or anticoagulation, etc.) because it is assumed that VBI is not ischemic (not TIA or infarction).
To completely correct this confusing situation, the following effective measures must be taken. First, the national academic diagnostic criteria must be updated based on clinical evidence, and the concept of “posterior circulation ischemia” should be adopted instead of the misleading concept of “inadequate blood supply to the basilar artery”. Second, a large national clinical database should be established. Thirdly, we should actively promote and carry out continuing medical education using the new concept.
The anatomical basis of vertigo is the balance triad, and the maintenance of normal spatial image depends on the visual, deep sensory and vestibular systems, which are called “balance triad”.
1. Vision: provides the orientation of the surrounding objects and the relationship between the body and the surrounding objects.
2.Deep sensory: transmits the sensation of limb joints and body posture.
3. Vestibular system: transmits the orientation and speed of movement of the body.
Although visual and deep sensory senses are involved in maintaining normal spatial image, their lesions rarely complain of vertigo. Vestibular pathology is the main cause of pathological vertigo.
Ideas for outpatient diagnosis of vertigo.
Determine whether it is vertigo or dizziness or lightheadedness based on the presence or absence of concomitant rotation of visual objects or swaying of oneself.
Determine whether the vertigo is central or peripheral based on the presence or absence of hearing impairment and other features.
If central vertigo, determine the central cause: vascular or posterior cranial fossa lesions.
If peripheral vertigo, further determine the peripheral etiology: inner ear vertigo disease or inner ear vertigo sign.
Exclude organic causes and consider functional vertigo.
Benign positional vertigo: also known as inner ear otoliths, age of onset 30-60 years, most common in the elderly. The otolith in the inner ear is displaced by gravity due to the change of the head and stimulates the vestibular nerve endings causing vertigo and nystagmus. When in a certain head position, vertigo suddenly appears and lasts for a short period of time, from a few seconds to tens of seconds. Nystagmus is rotational or horizontal, lasting 10-20 seconds, without hearing impairment, and can be induced by repeated changes of head position. A positive head position or postural test may be the only sign. The disease is a self-limiting condition with a good prognosis, with most patients gradually resolving in a few days or months, usually in 6-8 weeks. The diagnosis of this disease requires caution and attention to differentiate it from common causes of vertigo.