Cristiana Borges Pereira

Diagnóstico e tratamento das principais síndromes vestibulares

The aims of this study were to identify the most common vestibular syndromes in a dizziness unit, and to observe their clinical aspects and response to treatment. Five hundred and fifteen patients were studied retrospectively in two institutions. Aspects of anamnesis, physical examination and the response to treatment were evaluated. The most frequent syndromes were: benign paroxysmal positioning vertigo (VPPB) (28.5%), phobic postural vertigo (11.5%), central vertigo (10.1%), vestibular neuritis (9.7%), Meniere disease (8.5%), and migraine (6.4%). A good response to treatment was observed in most patients with migraine (78.8%), VPPB (64%), vestibular neuritis (62%), Meniere disease (54.5%) and vestibular paroxismia (54.5%). On the other hand, patients with downbeat nystagmus and bilateral vestibulopathy had poor response (52.6% and 42.8%, respectively). The diagnosis of these most frequent vestibular syndromes were established through anamnesis and physical examination (with specific clinical tests for evaluation of the vestibular function). The correct diagnosis and adequate treatment are important since these syndromes may have a good prognosis.

Vertigem postural fobica: aspectos clinicos e evolutivos

Phobic postural vertigo (PPV) is the second most common diagnosis on a dizziness unit. It is a somatoform syndrome characterized as a chronic and incapacitating condition with subjective imbalance and short attacks of dizziness. During a period of 18 months, PPV was observed in 41 patients among 251 of a dizziness unit. Twenty-six had primary PPV, among whom 65% had depressive or anxiety disorders, and 15 patients were diagnosed at secondary PPV. Normal neurological examination and diagnostic tests were observed in most cases. A favorable response to treatment (antidepressants, benzodiazepines, psychotherapy and/or orientation) was observed in 62% of all patients, without difference between both groups - primary and secondary PPV. Despite the high prevalence, PPV is misdiagnosed. Therefore one must attempt to recognize it, since its appropriate treatment prevents recurrence and incapacitation.

Vertigem de posicionamento paroxística benigna

Benign paroxysmal positioning vertigo is a frequent vestibular disorder. With a simple maneuver one can easily diagnose this condition and treatment is based on liberatory maneuvers. On this review the pathogenesis, the clinical features and different maneuvers are briefly discussed.

Correlation of impaired subjective visual vertical and postural instability in Parkinson's disease.

Perception of verticality is essential for postural control. On the other hand, postural instability is one of the cardinal features in Parkinsons disease (PD). Thus, the objective of this study was to evaluate the vertical perception using the subjective visual vertical test in PD patients with different degrees of postural instability and in different stages of disease. Forty five idiopathic PD patients were evaluated using the Unified Parkinsons Disease Rating Scale (UPDRS), the Hoehn and Yahr Scale, the clinical test for postural instability, and the subjective visual vertical test. Forty-five healthy individuals were evaluated in the control group. PD patients had a compromised perception of verticality and a disturbed processing of graviceptive pathways. Good correlation was also found between subjective visual vertical and postural instability. Patients with the worst postural instability had greater deviations of subjective visual vertical. There was also a positive correlation between subjective visual vertical and scores on the UPDRS and Hoehn and Yahr Scale, with good and reasonable degree of intensity, respectively. These findings suggest that the perception of verticality is affected in PD patients and this abnormal vertical perception and disturbed processing of graviceptive pathways are associated with postural instability and to a lesser degree with disease severity.

Avaliação da vertical visual subjetiva em indivíduos brasileiros normais

A funcao otolitica pode ser avaliada pela Vertical Visual Subjetiva (VVS) que determina a capacidade de um individuo julgar se objetos estao na posicao vertical na ausencia de outras referencias visuais. O objetivo deste estudo foi avaliar a VVS em individuos brasileiros normais usando um aparelho portatil. As medidas da VVS foram realizadas em 160 individuos (16 a 85 anos). O valor medio da VVS foi obtido apos dez ajustes. A VVS teve valores medios entre -2,0o e +2,4o (media=0,18o, e DP=0,77o). Nao houve diferenca entre as medias da VVS em relacao a idade (teste de Kruskal-Wallis; p=0,40), mas as faixas etarias maiores tiveram variância maior (teste de Levene; p=0,016). Os valores da VVS encontrados neste estudo foram semelhantes aos registrados na literatura. Nao houve diferenca nas medias das inclinacoes da VVS de acordo com a idade, mas foi encontrada maior variância entre individuos mais idosos.

Psychological assessment in patients with phobic postural vertigo

UNLABELLED Phobic postural vertigo (PPV) is a frequent diagnosis which can be challenging to treat. OBJECTIVE To investigate the presence of psychiatric disturbances in patients with PPV; to assess the psychological status of patients using adaptive diagnosis; to verify possible correlations between severity of psychiatric disturbance and adaptive efficacy. METHOD A total of nineteen subjects were assessed and two instruments applied: the Primary Care Evaluation of Mental Disorders Questionnaire (PRIME-MD) and the Adaptive Operationalized Diagnostic Scale (AODS), and results from both tests were compared. RESULTS Fourteen patients presented with mood disorder and thirteen with anxiety. All patients presented compromised adaptive efficacy. Correlation was found between overall outcome on the PRIME and the AODS (tau= -0.42, p=0.027), Separate analysis revealed correlation between results of the AODS and anxiety disorders (tau= -0.45, p=0.018) but not with mood disorders (tau= -0.36, p=0.054). CONCLUSION Adaptive compromise was observed in individuals with PPV which was shown to be associated to psychiatric disorders.

Multidisciplinary Assessment of Patients with Musical Hallucinations, Tinnitus and Hearing Loss

Background: Although auditory hallucinations are considered a psychopathological phenomenon, musical hallucinations have been reported in individuals without psychosis but with auditory symptoms (tinnitus and/or hearing loss). Thus, a possible different cognitive functioning may be involved in musical hallucinations. The aim of the study was to characterize patients with tinnitus and musical hallucinations through a multidisciplinary assessment, allowing a better understanding of these concomitant phenomena. Sampling and Methods: As this sample is rare to find, all consecutive patients with tinnitus, hearing loss and musical hallucinations were included over a 3-year period, excluding those unable to respond. All subjects underwent the following assessments: (1) otolaryngological and audiological assessment (physical examination and audiometry), (2) neurological assessment (cognition, electroencephalogram and imaging examination) and (3) psychiatric assessment (structured interview). Results: A total of 16 patients were included (87.5% women; mean age 61.43 ± 15.99 years). The otolaryngological examination was normal in all cases, but audiometry revealed that the degree of hearing loss was severe to profound in 68.75% of participants. Neurological assessment showed electroencephalogram changes in only 17.6% of cases, while 25% presented with mild attention deficit and 43.75% had small foci of gliosis or ischemia on the imaging examination. Psychiatric assessment showed that 68.75% of cases had depression, 6.25% had anxiety disorder and 25% had no psychiatric conditions. Conclusions: Musical hallucinations were strongly associated with female elderly adults and with mood disorders. Thus, in contrast to common auditory hallucinations, patients with musical hallucinations associated with tinnitus and hearing loss should be offered a more multidisciplinary assessment.

Assessment of gait deviation on the Babinski-Weill test in healthy Brazilians

OBJECTIVE The aim of this study was to validate a simple and reproducible method for assessing gait deviation on the Babinski-Weill test in a representative sample of healthy Brazilians. METHODS Gait deviations were measured in 75 individuals (median=30 years, 41 women) for forward, backwards, and Babinski-Weill steps. The test entailed blindfolded individuals walking 10 paces at a frequency of 1 Hz with deviations subsequently measured by a protractor. RESULTS Mean gait deviation forward was 0.53° with standard deviation (SD)=4.22 and backwards was 2.14° with SD=4.29. No significant difference in deviation was detected between genders (t test p=0.40 forward and p=0.77 backwards) or for age (ANOVA, p=0.33 forward and p=0.63 backwards). On the Babinski-Weill test, mean gait deviation was 5.26°; SD=16.32 in women and -3.11°; SD=12.41 in men, with no significant difference between genders (t test, p=0.056). DISCUSSION Defining normative gait patterns helps distinguish pathological states.

Retropulsion and vertigo in the Chiari malformation: case report

We describe a rare case of a 30 year-old woman with intense vertiginous sensation, lack of body balance and a tendency to fall backwards, making it necessary for two people to sustain her. The magnetic resonance imaging of the craniocervical junction evidenced tonsilar herniation at the inferior level of C1, and during the operation performed in sitting position, we observed crowding of the cerebellar tonsils at the level of C3. After the osteo-dural-neural decompression, the symptomatology remitted on the same day of the operation.

High doses of carbamazepine for refractory partial epilepsy

Forty-eight patients with partial seizures were analysed during treatment with 1200 mg/d or more of carbamazepine (CBZ). Thirty-three were on monotherapy and fifteen on polytherapy. The other drugs were kept unchanged in the patients on polytherapy. The dose of CBZ was increased if no control was observed and the patient had no side effects. The doses used ranged between 1200 and 1900 mg/day (1200 mg/day, n = 18; 1300 mg/day, n = 1; 1400 mg/day, n = 7; 1600 mg/day, n = 9; 1700 mg/day, n = 4; 1800 mg/day, n = 8; 1900 mg/day, n = 1). Anticonvulsant plasma levels were taken to confirm patient compliance. The average plasma level was 9.6 ug/mL. The period of follow up varied from 3 to 96 months (M = 25.6). Seizures control was observed in 7 (14.48%) patients taking 1200 mg/day and in 2 (4.16%) patients taking 1400 mg/day of CBZ. Thirty-nine patients did not show any control (81.21%). Ten patients (20.81%) had signs of intoxication. When patients have no improvement with 1400 mg/day, it is difficult to obtain any control despite the use of higher doses of CBZ, which frequently expose the patient to significant side effects.