New York Otology, New York Head and Neck Institute, 1421 Third Avenue, 4th Floor, New York, NY 10028, USA.
NeuroRehabilitation. 2013;32(3):445-54. doi: 10.3233/NRE-130867.
All degrees of traumatic brain injury (TBI) are associated with balance dysfunction and/or dizziness. The clinician assessing and managing patients with TBI should become familiar with vestibular and non-vestibular causes of dizziness and imbalance, and be able to perform screening tests to determine when referral to a vestibular specialist is warranted. This chapter outlines the clinical pathways to be followed in history-taking, physical examination, and assessment.
Dizziness, vertigo, balance dysfunction and gait ataxia can have their origin in the vestibular system, elsewhere, or be multifactorial. The complex anatomy and physiology of the balance canals, otolithic organs, and vestibular nerves peripherally, and the vestibular nuclei centrally, as well as the neural connections between vestibular, oculomotor, and proprioceptive systems will be covered in clinically pertinent detail.
A majority of diagnosis of dizziness/vertigo can be made after a proper history has been obtained. This can be challenging in all dizzy patients, and more so in the TBI patient in whom memory and recall may be impaired. The reader will learn how to use tools such as dizziness questionnaires as well as targeted history taking to elicit the information. Similarly, the addition of a programmatic, targeted physical examination of the dizzy patient will allow the clinician to fine-tune the diagnosis between peripheral and central causes.
Once history and examination have narrowed the diagnostic possibilities, appropriate testing--in the vestibular laboratory and radiologic testing--is indicated. The reader will learn when these tests should be considered, and what the findings will show. Treatment can then be targeted for maximal outcome.
Managing TBI is challenging; the addition of dizziness or balance complaints in these individuals makes it even more so. This paper seeks to provide a useful roadmap clinical pathway for assessment of these patients with appropriate and timely referral for treatment.
所有程度的创伤性脑损伤（TBI）都与平衡功能障碍和/或头晕有关。评估和管理 TBI 患者的临床医生应熟悉头晕和平衡障碍的前庭和非前庭原因，并能够进行筛查测试，以确定何时需要向前庭专家转诊。本章概述了在病史采集、体格检查和评估中应遵循的临床路径。
头晕、眩晕、平衡功能障碍和步态共济失调可能起源于前庭系统，也可能起源于其他部位，或者是多因素的。平衡管、耳石器官和前庭神经在周围的复杂解剖结构和生理学，以及前庭核在中枢的复杂解剖结构和生理学，以及前庭、眼动和本体感觉系统之间的神经连接，将以与临床相关的详细信息进行介绍。
在获得适当的病史后，大多数头晕/眩晕的诊断都可以做出。在所有头晕患者中，这可能具有挑战性，而在 TBI 患者中，由于记忆和回忆可能受损，这更具挑战性。读者将了解如何使用头晕问卷等工具以及有针对性的病史采集来获取信息。同样，对头晕患者进行有计划的、有针对性的体格检查，也可以使临床医生更准确地诊断出周围性和中枢性病因。
一旦病史和检查缩小了诊断可能性，就需要进行适当的测试——在前庭实验室和影像学检查中。读者将了解何时应考虑这些测试，以及测试结果将显示什么。然后可以针对最大的治疗效果进行治疗。
TBI 的管理具有挑战性；在这些患者中添加头晕或平衡问题使情况更加复杂。本文旨在为这些患者的评估提供一个有用的临床路径图，并为及时转诊治疗提供适当的指导。
