Article

Isolated dizziness/vertigo, vascular risk factors and stroke.

Department of Neurology, Neurological Institute, Taipei Veterans General Hospital and National Yang-Ming University School of Medicine.
Acta neurologica Taiwanica 06/2011; 20(2):75-6.
Source: PubMed

ABSTRACT

Dizziness is a common symptom encountered in everyday clinical practice, affecting about 20% to 30% of the general population (1).The number is even higher in the elderly. It is estimated that around 7.5 million patients with dizziness were seen in ambulatory care setting in the U.S. (2), making it the most common principal complaint in the emergency department. The term "dizziness' is very nonspecific, but may refer to vertigo, which is the sensation of spinning, lightheadedness, presyncope, or feeling of imbalance. It is often associated with depressed mood, poor self-rated health, falls, and a reduction in social activities (3). Most of the causes (over 75%) are peripheral vestibular disorders, such as benign paroxysmal positional vertigo, vestibular neuritis or labyrinthitis (4-5). Central causes account for less than 25% of the cases. The diagnosis of vertebrobasilar insufficiency (VBI) is obvious when the dizziness/vertigo is accompanied by other neurological symptoms, e.g. ataxia, diplopia, and nystagmus. However, when vertigo/dizziness occurs in isolation, it is difficult to differentiate vascular causes from other, more benign peripheral vestibular disorders. There have been conflict results in the estimate on the role of vascular insufficiency in patients with isolated dizziness/vertigo( 2, 6-12). In this issue, Chang and colleagues systemically evaluate 170 evaluated subjects receiving self-paid health check-up of the cerebrovascular system, including brain magnetic resonance imaging (MRI), serum biochemistry and vascular risk factors screening, to investigate the relationship between vascular risk factors and isolated dizziness/vertigo (13). Twenty-eight out of the 170 subjects complained of chronic isolated dizziness/ vertigo. They found that old age, obese female, higher uric acid level and MRI evidence of leukoaraiosis were significantly associated with chronic isolated dizziness/vertigo. Grad and Baloh found a high incidence of isolated episodes of vertigo during their course of disease in a retrospective review of 84 cases with VBI or brainstem infarction (7). Sixty-two percent of patients with VBI had at least one isolated episode of vertigo; in 19% VBI began with isolated episode of vertigo. Transient ischemic in the vestibular labyrinth ischemia was highly suspected in these cases. Similarly, Gomez et al. found a high incidence (6/29) of widespread vascular insufficiency in the VB system in patients with long-standing (> 4 weeks) isolated vertigo (10). In addition, these patients had multiple vascular risk factors in common. This was confirmed by a recent study (11). Moubayed and Saliba reviewed the morphologic results of vertebral arteries (VA) by magnetic resonance angiography (MRA) in 133 patients. Compared to normal VAs, those with VA stenosis or hypoplasia (61 cases) had higher frequency of isolated positional vertigo or dizziness (85.7% vs. 58%). Furthermore, those with VA abnor- Editorial Acta Neurol Taiwan 2011;20:75-76 malities had more stroke risk factors (≧3) than patients with normal VA. The results of Chang et al. study (13) essentially paralleled these previous studies, i.e. patients with isolated dizziness/vertigo of presumably vascular origin were older, had higher body mass index (BMI), metabolic derangement, and more stroke risk factors. The most frequent sites of pathology in patients with isolated dizziness/vertigo are brainstem and/or cerebellum. Yamasoba et al. reported on a high prevalence of lacunar infarcts in the hindbrain in aged patients with chronic dizziness (9). Chan et al. reported on a case of pontine infarction due to VA thrombosis presenting with chronic isolated vertigo (14). Colledge et al. found more white matter lesions especially in the midbrain in aged dizzy patients (≧65) compared to control subjects (6). These authors postulated that cerebral small vessel disease could cause dizziness in susceptible patients. The underlying mechanism of higher frequency of leukoaraiosis in Chang et al. study (13) might be the same. Given the high prevalence of isolated dizziness/vertigo in our everyday practice, additional researches are warranted to further delineate the role of vascular risk factors and cerebral small vessel disease in these patients.

Full-text

Available from: Li-Chi Hsu
75
Acta Neurologica Taiwanica Vol 20 No 2 June 2011
75
From the Department of Neurology, Neurological Institute,
Taipei Veterans General Hospital and National Yang-Ming
University School of Medicine.
Accepted June 15, 2011.
Correspondence to: Li-Chi Hsu, M.D, Department of
Neurology, Taipei Veterans General Hospital, No. 201, Sec. 2,
Shih-Pai Road, Taipei, Taiwan, 11217.
E-mail: lchsu@vghtpe.gov.tw
Isolated Dizziness/Vertigo, Vascular Risk Factors and Stroke
Li-Chi Hsu
Dizziness is a common symptom encountered in
everyday clinical practice, affecting about 20% to 30%
of the general population
(1)
.The number is even higher
in the elderly. It is estimated that around 7.5 million
patients with dizziness were seen in ambulatory care
setting in the U.S.
(2)
, making it the most common princi-
pal complaint in the emergency department.
The term “dizziness” is very nonspecific, but may
refer to vertigo, which is the sensation of spinning,
lightheadedness, presyncope, or feeling of imbalance. It
is often associated with depressed mood, poor self-rated
health, falls, and a reduction in social activities
(3)
. Most
of the causes (over 75%) are peripheral vestibular disor-
ders, such as benign paroxysmal positional vertigo,
vestibular neuritis or labyrinthitis
(4-5)
. Central causes
account for less than 25% of the cases. The diagnosis of
vertebrobasilar insufficiency (VBI) is obvious when the
dizziness/vertigo is accompanied by other neurological
symptoms, e.g. ataxia, diplopia, and nystagmus.
However, when vertigo/dizziness occurs in isolation, it
is difficult to differentiate vascular causes from other,
more benign peripheral vestibular disorders. There have
been conflict results in the estimate on the role of vascu-
lar insufficiency in patients with isolated dizziness/verti-
go
(2, 6-12)
.
In this issue, Chang and colleagues systemically
evaluate 170 evaluated subjects receiving self-paid
health check-up of the cerebrovascular system, includ-
ing brain magnetic resonance imaging (MRI), serum
biochemistry and vascular risk factors screening, to
investigate the relationship between vascular risk factors
and isolated dizziness/vertigo
(13)
. Twenty-eight out of
the 170 subjects complained of chronic isolated dizzi-
ness/vertigo. They found that old age, obese female,
higher uric acid level and MRI evidence of leukoaraio-
sis were significantly associated with chronic isolated
dizziness/vertigo.
Grad and Baloh found a high incidence of isolated
episodes of vertigo during their course of disease in a
retrospective review of 84 cases with VBI or brainstem
infarction
(7)
. Sixty-two percent of patients with VBI had
at least one isolated episode of vertigo; in 19% VBI
began with isolated episode of vertigo. Transient
ischemic in the vestibular labyrinth ischemia was highly
suspected in these cases. Similarly, Gomez et al. found a
high incidence (6/29) of widespread vascular insuffi-
ciency in the VB system in patients with long-standing
(> 4 weeks) isolated vertigo
(10)
. In addition, these
patients had multiple vascular risk factors in common.
This was confirmed by a recent study
(11)
. Moubayed and
Saliba reviewed the morphologic results of vertebral
arteries (VA) by magnetic resonance angiography
(MRA) in 133 patients. Compared to normal VAs, those
with VA stenosis or hypoplasia (61 cases) had higher
frequency of isolated positional vertigo or dizziness
(85.7% vs. 58%). Furthermore, those with VA abnor-
Editorial
Acta Neurol Taiwan 2011;20:75-76
Page 1
malities had more stroke risk factors (3) than patients
with normal VA. The results of Chang et al. study
(13)
essentially paralleled these previous studies, i.e. patients
with isolated dizziness/vertigo of presumably vascular
origin were older, had higher body mass index (BMI),
metabolic derangement, and more stroke risk factors.
The most frequent sites of pathology in patients with
isolated dizziness/vertigo are brainstem and/or cerebel-
lum. Yamasoba et al. reported on a high prevalence of
lacunar infarcts in the hindbrain in aged patients with
chronic dizziness
(9)
. Chan et al. reported on a case of
pontine infarction due to VA thrombosis presenting with
chronic isolated vertigo
(14)
. Colledge et al. found more
white matter lesions especially in the midbrain in aged
dizzy patients ( 65) compared to control subjects
(6)
.
These authors postulated that cerebral small vessel dis-
ease could cause dizziness in susceptible patients. The
underlying mechanism of higher frequency of
leukoaraiosis in Chang et al. study
(13)
might be the same.
Given the high prevalence of isolated dizziness/ver-
tigo in our everyday practice, additional researches are
warranted to further delineate the role of vascular risk
factors and cerebral small vessel disease in these
patients.
REFERENCES
1. Karatas M. Vascular vertigo: epidemiology and clinical
syndromes. Neurologist 2011;17:1-10.
2. Burt CW, Schappert SM. Ambulatory care visits to physi-
cian offices, hospital outpatient departments, and emer-
gency departments: United State 1999-2000. Vital Health
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3. Tinetti ME, Williams CS, Gill TM. Health, functional and
psychological outcomes among older persons with chronic
dizziness. J Am Geriatr Soc 2000;48:417-421.
4. Hain TC, Micco A. Neuroanatomical localization and syn-
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5. Johkura K, Momoo T, Kuroiwa Y. Positionall nystagmus in
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6. Colledge N, Lewis S, Mead G, Sellar R, Wardlow J, Wilson
J. Magnetic resonance brain imaging in people with dizzi-
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7. Grad A, Baloh RW. Vertigo of vascular origin: clinical and
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8. Norrving B, Magnusson M, Holtas S. Isolated acute vertigo
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9. Yamasoba T, Kikuchi S, Higo R, Kaga K, O’uchi T,
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10. Gomez CR, Cruz-Flores S, Malkoff MD, Sauer CM, Burch
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11. Moubayed SP, Saliba I. Vertebrobasilar insufficiency pre-
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12. Kerber KA, Meurer WJ, West BT, Fendrich M. Dizziness
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Emerg Med 2008;15:744-750.
13. Chang CC, Chang WN, Huang CR, Liou CW, Lin TK, Lu
CH. The relationship between isolated dizziness/vertigo
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Acta Neurol Taiwan 2011;20:101-106.
14. Chan LL, Tan EK, Tan KP. Chronic isolated vertigo. Int J
Clin Pract 2000;54:407-408.
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