头晕眩晕诊断思路

头晕/眩晕

正确诊断的来源是基本功上海交通大学医学院附属仁济医院

神经科李焰生

对头晕/眩晕的认识

椎基底动脉供血不足诊断标准

中华神经精神科杂志1988；21：:14眩晕的临床诊断和治疗流程建议

中国神经精神疾病杂志2003；29:314中国后循环缺血的专家共识

中华内科学杂志2006；45：786头晕的诊断流程建议

中华内科杂志2009；48:435眩晕诊治专家共识

中华神经科杂志2010；43：6:3

正确诊断的基本功•症状界定是诊断前提•仔细问诊是诊断关键•了解病因是诊断保证•针对检查是诊断支持•更新知识是诊断源泉

头晕（dizziness）

•韦氏医学字典定义为“由视觉、脑部、内耳平衡及胃肠道疾患所导致的非痛性头部不适。头晕是个难以界定的医学术语，非专业人员常用之以描述从头重脚轻、不稳到眩晕等多种情况。”

•维基百科全书中指“空间知觉和平衡的损害，它是不精确的，被用以表示眩晕(vertigo)、晕厥前（presyncope、near faint）、失衡（disequilibrium或imbalance或unsteadiness）非特异性头重脚轻（lightheadness）”

vertigo

•韦氏医学字典定义: vertigo来自拉丁语，vertere表示“旋转”，后缀igo表示“状态”，故指自身或

周围环境旋转的感觉。

•维基百科全书中指“是头晕的一种，是种运动感，常由前庭系统功能异常所导致，常伴随有恶心、呕吐、站立和行走困难。”

DIZZINESS : quality-of-symptom

1.眩晕(vertigo)

特异性症状，感觉环境在旋转，各方向皆有，头活动后加重

2.失衡(disequilibrium或imbalance或unsteadiness)

不稳或不安全感，无旋转，站立和行走困难

3.头重脚轻(lightheadedness)

头或环境有“游泳”、漂浮、晕或摇摆感

4.晕厥前（pre-syncope或near faint)

一过性、马上要失去知觉、晕倒的感觉

Drachman DA，Hart CW. An approach to the dizzy patient. Neurology,1972, 22: 323–334

Cecil Textbook of Medicine 24edi 2010

The term dizziness include lightheadedness, disequilibrium, vertigo, and presyncope and has numerous potential causes.Description, mechanism, and focus of diagnostic workup for common

types of dizziness

type

description

mechanism

Focus of diagnostic evaluation vertigo Spinning(environment moves), tilt,drunkeness Imbalance in tonic vestibular activity

Auditory and vestibular systems Near faint Lightheaded, swimming

Decreased blood flow to entire brain

Cardiovascular system psychophysiologic

Dissociated from body, spinnning inside(environment still)Impaired central integration of sensory signals Psychiatric assessment disequilibrium

Off balance, unsteady on foot

Loss of vestibulospinal,

proprioceptive, cerebellar, or motor function

Neurological assessment

Adams & Victor’s Principles of Neurology 9th Edition 2009

The term dizziness is applied by the patient to a number of different sensory experiences —a feeling of rotation or whirling as well as nonrotatory swaying, weakness, faintness, light-headedness, or unsteadiness. Blurring of vision, feelings of unreality, syncope, and even petit mal or other seizure phenomena may be called "dizzy spells." These experiences fall into four categories:

(1) vertigo , a physical sensation of motion of self or the environment;(2) near syncope , a sensation of faintness;

(3) disequilibrium , a disorder imbalance of stance or gait;

(4) ill-defined lightheadedness, a symptom that often accompanies anxiety.

Hence a close questioning of the patient as to how he is using the term dizziness becomes a necessary first step in clinical study.

Neurology in Clinical Practice

5th edi 2008

Dizziness is a term patients used to describe a variety of

symptoms including spinning or movement of the environment (vertigo), lightheadedness, presyncope, or imbalance. Patients also may use the term for other sensations such as visual distortion, internal spinning, nonspecific disorientation, and anxiety, so the most important initial step is to clarify the symptoms. Peripheral vestibular disorders are important to recognize because they are common and difinable at the bedside and often are missed by referring physicians.

Common causes of nonspecific dizziness: patients usually have

lightheadedness(wooziness),presyncope, imbalance, motion sensitivity, or anxiety. Elderly, cardiology, metabolism, peripheral neuropathy, medication Common presentation of vertigo:

acute severe vertigo: vestibular neuritis, stroke

recurrent vertigo: meniere disease, migraine, vestibular paroxysma, TIA recurrent positional vertigo: BPPV

按照quality-of-symptom 分类的问题

•患者常常将头晕和眩晕等同

•不少患者几乎不能将不同情况区分，或无法分清到底如何（也有多种充分混合可能）•欧洲与美国专家不一致

•故仅依据患者的诉说来确定症状性质不是很可靠

入选2个医院急诊患者872例，主诉头晕、头重脚轻或不稳；44%因此而来急诊，问卷分析：62%选择1种以上头晕类型；

54%的回答与救诊时的描述不一致；

218例在问卷中没有选择“旋转、眩晕”者中，70%直接提问回答时有“眩晕、旋转”；

52%患者6分钟内的前后回答不一致，而持续时间和诱因很一致

结论：头晕性质的描述不清、不一致、不可靠！