Dizzy Spells Research Articles

Why do adult women in Vietnam take iron tablets?

BackgroundConducting iron supplementation programs has been a major strategy to reduce iron deficiency anemia in pregnancy. However, only a few countries have reported improvements in the anemia rate at a national level. The strategies used for control of nutrition problems need regular review to maintain and improve their effectiveness. The objective of this study was to analyze the factors in compliance with taking iron tablets, where daily doses of iron (60 mg) and folic acid (400 μg) were distributed in rural Vietnamese communes.MethodsA cross sectional survey was conducted in Nghe An province, Vietnam in January, 2003. The study population was adult women aged less than 35 years who delivered babies between August 1st 2001 and December 1st 2002 (n = 205), of which 159 took part in the study. Data for the study were collected from a series of workshops with community leaders, focus group discussions with community members and a questionnaire survey.ResultsImprovements in the rate of anemia was not given a high priority as one of the commune's needs, but the participants still made efforts to continue taking iron tablets. Two major factors motivated the participants to continue taking iron tablets; their experience of fewer spells of dizziness (50%), and their concern for the health of their newborn baby (54%). When examining the reasons for taking iron tablets for at least 5–9 months, the most important factor was identified as 'a frequent supply of iron tablets' (OR = 11.93, 95% CI: 4.33–32.85).ConclusionThe study found that multiple poor environmental risk factors discouraged women from taking iron tablets continuously. The availability (frequent supply) of iron tablets was the most effective way to help adult women to continue taking iron tablets.

Syncope and falls due to timolol eye drops

The prevalence of glaucoma increases with age.1 Timolol, a non-selective β blocker, is the first line treatment. We present three cases from our falls clinic, in which we show that...

Emergency contraception: a contraceptive intervention approaching target despite controversy and opposition

The objective of this study is to make the public aware of progress, safety, effectiveness of use, acceptance, and over-the-counter availability of emergency contraception (EC). Data were extracted from the literature for the period 2000–2006 via MEDLINE using a keyword, and also from some pre-2000 journals. Randomised trials, reviews, surveys, clinical investigations, and articles relevant to the subject matter are considered in this review. Approximately 85%, 57% and 84% of unintended pregnancy could be prevented by using levonorgestrel, the Yuzpe regimen (levonorgestrel plus ethinylestradiol), and mifepristone, respectively, as EC. Levonorgestrel was more effective than the Yuzpe regimen in preventing pregnancy. A dose of 1.5 mg levonorgestrel seemed to have similar effectiveness as that of split doses (0.75 mg twice) at 12 h apart, and that of a low-dose (10 mg) of mifepristone. Nausea and vomiting, dizzy spells and fatigue were less frequent in women using levonorgestrel only than in those receiving the Yuzpe regimen. The mode of action of EC is associated primarily with inhibition of ovulation. EC acts before implantation and hence does not amount to abortion. Teenagers are more likely to be repeat users of EC. Easy access to EC over the counter is likely to increase its use but will widen the chance of misuse or abuse. Both adolescents and health care providers need to be adequately educated and informed about EC to make this method successful. Over the counter supply of EC without prescription but with pharmacists’ counselling may increase reduction of unintended pregnancy and abortion. The controversy surrounding, and opposition to, EC may subside with more awareness and knowledge among the public about its mode of action, safety and effectiveness. Educational programmes on EC and further studies on the psychosocial aspects of its use may resolve hurdles for implementation of ‘advance provision’ or ‘over the counter supply’ of EC in the community.

Diabetes, Dizzy Spells, and Erectile Dysfunction as Presenting Symptoms in a Patient With Pheochromocytoma

Diabetes, Dizzy Spells, and Erectile Dysfunction as Presenting Symptoms in a Patient With Pheochromocytoma

A universal menopausal syndrome?

A variety of symptoms are reported frequently as being part of a menopausal syndrome. These include hot flashes, night sweats, menstrual irregularities, vaginal dryness, depression, nervous tension, palpitations, headaches, insomnia, lack of energy, difficulty concentrating, and dizzy spells. The question of whether and how symptoms occur together is an important one for women who want to know which symptoms can be attributed to menopause and which to aging generally or to other physical or psychosocial factors. To address this question, the present article examines the following avenues of research: (1) the clustering or grouping of symptoms; (2) the temporal association of different symptoms with stages of the menopausal transition; (3) the consistency of symptom reporting across culture, race, and ethnicity; and (4) the consistency of risk factors for symptoms. Results of the factor analysis studies do not support a single syndrome consisting of menopausal and psychological or somatic symptoms. The prevalence of symptom reporting across the transition also argues against a menopausal syndrome because vasomotor symptoms follow a unique pattern that differs from other symptoms. Cross-cultural differences suggest that symptom reporting is not universal. Finally, although there is some overlap in risk factors for symptoms, menopausal status is more consistently related to vasomotor symptoms than psychological or physical ones. Results of these investigations all argue against a universal menopausal syndrome. Future research should focus on how symptoms are interrelated, what factors are uniquely related to vasomotor symptoms, and identifying whether there is a subgroup of women who are more likely to report symptoms. A variety of symptoms are reported frequently as being part of a menopausal syndrome. These include hot flashes, night sweats, menstrual irregularities, vaginal dryness, depression, nervous tension, palpitations, headaches, insomnia, lack of energy, difficulty concentrating, and dizzy spells. The question of whether and how symptoms occur together is an important one for women who want to know which symptoms can be attributed to menopause and which to aging generally or to other physical or psychosocial factors. To address this question, the present article examines the following avenues of research: (1) the clustering or grouping of symptoms; (2) the temporal association of different symptoms with stages of the menopausal transition; (3) the consistency of symptom reporting across culture, race, and ethnicity; and (4) the consistency of risk factors for symptoms. Results of the factor analysis studies do not support a single syndrome consisting of menopausal and psychological or somatic symptoms. The prevalence of symptom reporting across the transition also argues against a menopausal syndrome because vasomotor symptoms follow a unique pattern that differs from other symptoms. Cross-cultural differences suggest that symptom reporting is not universal. Finally, although there is some overlap in risk factors for symptoms, menopausal status is more consistently related to vasomotor symptoms than psychological or physical ones. Results of these investigations all argue against a universal menopausal syndrome. Future research should focus on how symptoms are interrelated, what factors are uniquely related to vasomotor symptoms, and identifying whether there is a subgroup of women who are more likely to report symptoms.

A universal menopausal syndrome?

A variety of symptoms are reported frequently as being part of a menopausal syndrome. These include hot flashes, night sweats, menstrual irregularities, vaginal dryness, depression, nervous tension, palpitations, headaches, insomnia, lack of energy, difficulty concentrating, and dizzy spells. The question of whether and how symptoms occur together is important for women who want to know which symptoms can be attributed to menopause and which to aging generally or to other physical or psychosocial factors. To address this question, the present article examines the following avenues of research: (1) the clustering or grouping of symptoms; (2) the temporal association of different symptoms with stages of the menopausal transition; (3) the consistency of symptom reporting across cultures, race, and ethnicity; and (4) the consistency of risk factors for symptoms. Results of the factor analysis studies do not support a single syndrome consisting of menopausal and psychological or somatic symptoms. The prevalence of symptom reporting across the transition also argues against a menopausal syndrome because vasomotor symptoms follow a unique pattern that differs from that of other symptoms. Cross-cultural differences suggest that symptom reporting is not universal. Finally, although there is some overlap in risk factors for symptoms, menopausal status is more consistently related to vasomotor symptoms than to psychological or physical ones. Results of these investigations all argue against a universal menopausal syndrome. Future research should focus on how symptoms are interrelated, what factors are uniquely related to vasomotor symptoms, and identifying whether there is a subgroup of women who are more likely to report symptoms.

Risk factors for Fasciola hepatica infection in children: a case–control study

We conducted a case-control study to clarify the risk factors for human fascioliasis in the Northern Peruvian Altiplano. Cases (n=61) were individuals who were diagnosed as having chronic fascioliasis by faecal and/or serologic (Fas2-ELISA) studies. Controls (n=61) had negative serologic and coprological results for Fasciola hepatica. We identified an association between fascioliasis and four variables (40 analysed): the habit of drinking alfalfa juice (OR=4.5; 95% CI 1.8-11.1; P<0.001); familiarity with aquatic plants (OR=4.3; 95% CI 1.8-10.6; P<0.001); dog ownership (OR=5; 95% CI 1.7-15.1; P=0.002); and raising more than five sheep (OR=0.3; 95% CI 0.1-0.8; P=0.01). According to clinical presentation and laboratory studies, dizzy spells (P=0.01), history of jaundice (P=0.01), peripheral eosinophilia (P=0.005) and Ascaris lumbricoides in stools (P=0.001) were associated with fascioliasis. The principal exposure factor for F. hepatica infection was drinking alfalfa juice. In conclusion, we suggest that human fascioliasis in Peru should be suspected in patients from livestock-rearing areas, who present with recurrent episodes of jaundice and who have a history of consumption of alfalfa juice or aquatic plants, or who have eosinophilia.

Carotid Endarterectomy in Nonagenarians

The North American Symptomatic Carotid Endarterectomy Trial and the European Carotid Surgery Trial demonstrated that a greater benefit from carotid endarterectomy (CEA) was seen in elderly compared with younger patients. However, no patients older than 89 years were included in either study. We hypothesized that CEA is safe and effective in patients 89 years and older. This is a retrospective review of 3 neurosurgeons' CEA experience with nonagenarian patients. Of our 1800 patients who underwent CEA, 26 were 89 years or older. Twenty-three patients had had cerebral ischemic symptoms (unilateral hemispheric symptoms in 21 and 2 dizzy spells associated with bilateral high-grade stenosis). Cerebral angiography was performed in 3 patients. Twenty-three patients underwent noninvasive imaging. Four patients had bilateral high-grade stenosis and underwent staged bilateral CEA. All procedures were performed after the induction of general anesthesia with electroencephalographic (and, more recently, transcranial Doppler) monitoring and etomidate-induced burst suppression for cerebral protection during cross-clamping. Unusual technical difficulties were frequently noted, including high bifurcations, looping rotated internal carotid arteries, and marked adherence of surrounding soft tissues. In 3 of the 30 procedures, a shunt was used. There were no perioperative cerebral ischemic or cardiac events. The mean hospital stay was 2 days. One patient had a transient vocal cord paresis. Twenty-two patients were alive and well 24 months following the procedure. Four patients died of non-stroke-related causes. Carotid endarterectomy was successfully performed without perioperative cerebral or cardiac complications in our series of 26 patients 89 years and older undergoing 30 CEAs. Extrapolating from reported results from the North American Symptomatic Carotid Endarterectomy Trial and the European Carotid Surgery Trial, we believe CEA should be considered in nonagenarian patients with high-grade symptomatic carotid stenosis who are otherwise well medically. Our recommendations are less certain in the case of asymptomatic disease.

Dizzy spells in older people can often be treated successfully

Dizzy spells in older people can often be treated successfully

Isolated perverted head-shaking nystagmus in focal cerebellar infarction

Head-shaking nystagmus (HSN) refers to the nystagmus induced by head oscillation, and usually beats to the healthy side in unilateral peripheral vestibulopathy.1 It may occur from velocity storage mechanism and Ewald second law.1,2 In perverted HSN (pHSN), the nystagmus develops in the plane other than that being stimulated, i.e., downbeat or upbeat after horizontal head oscillation. pHSN has been reported in diffuse cerebellar degeneration or medullary lesion,3,4 and signifies central vestibular lesion. However, isolated pHSN from focal cerebellar lesions has not been described. A 59-year-old man reported recurrent dizziness that most often occurred from exposure to heat or after taking a hot bath and lasted several minutes without other neurologic symptoms. On initial examination, he had blood pressure of 155/95 mm Hg and fasting blood glucose of 206 mg/dL. Other physical, neurotologic, and routine laboratory examinations were normal. In view of hypertension, diabetes, and duration of the dizzy spells, he was suspected to have vertigo of vascular origin and was scheduled for brain MRI. Five days later, while …

Flight-associated inferior alveolar nerve paresthesia: A case report

Injury caused by strong pressure changes is generally referred to as barotrauma. It can affect several areas of the body, including ear, face, lungs, and teeth, where it is usually known as barodontalgia. It is sustained from the failure to equalize the pressure of an air-containing cavity to that of the surrounding environment.Although it is most often found in scuba divers, it can occur in air travel, and it has been reported also as a consequence of an air bag rupture and the high pressured air inhaled by the car driver during the accident. The first description of pressure-related disease was written by Paul Bert in 1878, when he noted symptoms of caisson disease in bridgeworkers, who, after finishing their shifts and coming back to the surface, presented dizzy spells, difficulties in breathing, and pain at abdomen and joints. This article represents the report of a case of inferior alveolar nerve paresthesia that appeared to be due to barotraumas.

Health sequelae of human cryptosporidiosis in immunocompetent patients.

There have been no systematic studies following up the longer term health effects of cases of cryptosporidiosis for which genotype data exist. We report a follow-up study of cases of laboratory-confirmed cryptosporidiosis. Case patients were sent a postal questionnaire asking about a wide range of symptoms occurring within 2 months after their initial diagnosis, and control subjects were sent the questionnaire 2 months after they had been recruited to the original study. Completed questionnaires were received from 235 case patients and 232 control subjects. For 111 of the case patients, the species of the infecting strain was known; 61 of these strains were Cryptosporidium hominis (human genotype), and 50 were Cryptosporidium parvum (bovine genotype). Forty percent of the case patients reported recurrence of intestinal symptoms after resolution of the acute stage of illness, irrespective of whether infection was with C. hominis or C. parvum. Reports of joint pain (odds ratio [OR], 2.8), eye pains (OR, 2.44), recurrent headache (OR, 2.10), dizzy spells (OR, 1.69), and fatigue (OR, 3.0) were significantly more common in case patients than in control subjects, but only in people who had experienced C. hominis infection. Joint symptoms experienced by case patients were of longer duration than those experienced by control subjects. Our results confirm previous reports of a high rate of relapse of gastrointestinal symptoms following recovery from an acute episode of cryptosporidiosis and show that C. hominis but not C. parvum is associated with an increased risk of nonintestinal sequelae. This study demonstrates that the impact of cryptosporidiosis on public health extends beyond that of the acute diarrheal illness and can lead to significant health sequelae.

Idolatry

I was feverish, the first time—in bed under two down comforters and still shivering. It was midsummer; I had the flu. Too glassy-eyed and dizzy, too flat-out miserable for once in my life to read (although I'd piled a hopeful foot-high stack of books on my night table, right next to the bottle of Smart Water the doctor had recommended to combat the dehydration that left me feeling drunk every time I stood up, sat up, or closed my eyes) and sick to death of sleeping, I was flipping channels on the little bedside TV my husband watches sports on. I started with HBO—the several channels' worth our cable company provides "as a courtesy" to the customers it overcharges anyway for just the one channel of HBO—and moved through Showtime (ditto), grumbling all the while about how it can be, how is it possible, that they broadcast movies twenty-four hours a day and yet never show anything I want to watch, before grimly beginning the round of the single digits: 4, 6, 8 . . . and stopped, stopped dead, at Channel 8, where a nervous-looking, bizarrely overdressed young woman was belting the hell out of a song from the forties—a fragment of a song, cut off after just a few bars and replaced by a clip of a young man, equally self-conscious, his tie untied in the style of Rat Pack-era Sinatra, stumbling through his song fragment. A talent show? A talent show! I nearly clapped my hands in pleasure (no doubt I would have, if I'd had the energy—if I hadn't been afraid that clapping, that pleasure, would have sent me over the edge, into the freefall of another dizzy spell) as I settled back on my pillows to watch. I love a talent show. That first night, I was so transfixed I didn't even think to call downstairs to my daughter, then nine years old—though if I'd stopped to think, as I did the next day, I would have realized that she'd be at least as interested as I. She's a sucker for talent, too, and for pop songs of all kinds—not to mention the sort of human interest story I'd already sniffed out here. That [End Page 49] first night, I just lay back on my pillows (a stack taller even than the stack of brand-new books I'd told myself I'd "use this time" to read after I'd been ordered to my bed), the two down comforters pulled up to my neck, and watched—with deep and growing pleasure—as the parade of awkward, unpolished, variously handsome young people, all of them groomed in an approximation of TV stardom (too much makeup, complicatedly styled and colored hair, wacky "glamorous" outfits that were clearly supposed to represent the look of the thirties and forties but didn't quite), sang and fidgeted and then stood tense and panting as they listened to the judgments passed on them by a panel of music industry professionals who seemed only slightly less self-conscious than they did. All the singers looked frightened. Even the ones who looked cocky also looked frightened. I understood why, too, after only a few minutes. This was the "results show," broadcasting the highlights of the actual competition that had been on TV the night before—I groaned, as this became clear to me (how I wished I hadn't missed it!)—but already I saw how it worked. The judges could say anything they wanted—they could be downright vicious if they felt like it ("That was just awful. Honestly, that was possibly the worst singing I have ever heard") or utterly opaque (one judge, it seemed, did little more than sigh and shake his head and mutter the contestant's name again and again)—and there was entertainment value in their pronouncements. A viewer could (and inevitably...

Cardiology patient pages. Ambulatory electrocardiographic recording.

Cardiac rhythm abnormalities are common. Although many arrhythmias are not harmful, some can cause symptoms and be a signal for potential cardiac arrest or stroke. Thus, the detection and quantification of these arrhythmias are important, especially for patients who have structural heart disease caused by an event such as a prior heart attack. Arrhythmias are frequently limited in duration and occurrence and cannot be detected during physical examination and routine electrocardiography (ECG) because these procedures permit only a few seconds of observation. To diagnose arrhythmias and to assess their relationship to patient symptoms, or to assess the effectiveness of an intervention to suppress them, longer periods of ECG recording are required while the patient is pursuing his or her normal routine. In this paper, we review the techniques and the clinical situations in which ambulatory ECG recordings are indicated. The most commonly used method of extended ECG recording is a Holter monitor (named for its inventor, Norman Holter) that uses a conventional tape recorder or solid-state storage system for acquiring ECG information that is later processed and displayed for physician review (Figure). Traditionally, these recordings are carried out for 24 to 48 hours via leads placed on the chest to yield 2 or 3 channels of ECG data. The patient is instructed to keep a diary of symptoms and to note the time on the Holter clock when the symptoms occur for later correlation to ECG abnormalities. For example, if the patient has a dizzy spell or rapid heart rhythm during the recording, the physician can determine if an arrhythmia, either fast or slow, was or …

外リンパろうに続発した内リンパ水腫例

We report a 26-year-old male patient with vertiginous sensation and sensorineural hearing loss of high frequency in his left ear after breathing strongly through his nose and hearing a pop sound. Because of his persistent dizzy spells and progressive hearing loss, we diagnosed perilymphatic fistula and performed an exploratory tympanotomy. We closed both oval and round windows with fascia, although we could not find any obvious fistula during surgery, resulting in reduction of dizziness and prevention of progressive hearing loss.One year after the operation, the patient came to complain about episodic vertigo with left fluctuating hearing loss. His audiogram showed left low tone sensorineural hearing deterioration and a glycerol test revealed endolymphatic hydrops in the left ear. we diagnosed secondary endolymphatic hydrops associated with perilymphatic fistula and performed endolymphatic sac drainage and steroid-instillation surgery. Follow-up for 6 months showed complete relief from vertigo and 11.3dB hearing improvement.

Filling the psychic gap: Understanding psychosomatic problems in a multi-cultural clinic

This paper describes an analytic approach I used some years ago when working in a multi-cultural clinic to understand psychosomatic difficulties in an Asian Muslim woman who suffered from recurring headaches and dizzy spells. Her symptoms revealed and concealed a much needed psychic equilibrium aimed at producing a stalemate in her mental growth and development. The headaches occurred when she began to think about herself, particularly conflicting thoughts and feelings which she found intolerable because it represented signs of psychic movement and separation. The dizzy spells acted like a psychic switch that closed her mind down and enabled her to escape into a phantasy of fusion with her mother which would have posed another type of psychic threat--the potential loss of her identity. Adopting others both literally and metaphorically had the aim of filling a psychic gap left by a failure of internalisation resulting in an 'addictive' way of relating to others such as her husband and the wider system of health care professionals who ultimately failed her.

Vascular dementia in patients with immune thrombocytopenic purpura

Introduction: Platelets have been implicated in memory disorders but this has not been investigated in patients with immune or idiopathic thrombocytopenia (ITP). ITP is an autoimmune disorder in which autoantibodies bring about platelet destruction. We previously reported a group of ITP patients who manifested TIA-like syndrome and gradual memory loss leading to dementia: platelet microparticles (PMP), a marker of platelet activation, were often elevated, suggesting that procoagulant PMP released from stimulated platelets contributed to thrombosis in small vessels. We have expanded on those studies to better define the clinical, laboratory, and radiologic characteristics of this syndrome. Materials and methods: Twenty ITP patients with this syndrome were studied in comparison to twenty-three ITP patients without it (patient controls). Clinical and laboratory features were compared and radiologic images were analyzed. Factors influencing the rate of progression to advanced dementia were also investigated. Results and conclusion: Recurring dizzy or weak spells, TIA-like syndrome, recent memory loss, and cognitive impairment were common initial complaints. In some, these symptoms progressed rapidly to dementia but was indolent in others. Progression was faster in those with splenectomy and higher platelet counts. MRI showed enhanced signal in subcortical, periventricular areas, consistent with ischemic small vessel disease. Compared to patient controls, bleeding was less frequent and platelet activation (increased PMP, CD62p) was more frequent in the study group. Thrombotic complications may occur in ITP, manifested as TIA-like syndrome or memory loss due to ischemic small vessel disease, progressing to vascular dementia. Memory disturbances associated with platelet disorders warrants further investigation.

Dizzy Spells and Syncope: Investigation and Management

Dizziness affects about one-third of individuals over the age of 65 years, and is one of the most common reasons for the elderly to consult their general practitioner. Syncope affects at least 20% of the population at some time and accounts for about 6% of general medical admissions in the UK. Recurrent symptoms are particularly disabling because they affect an individual's ability to work and to drive, increase susceptibility to falls and associated injuries, and reduce independence in the elderly.

An unusual case of blackouts in insulin-treated diabetes mellitus

54-year-old man presented with a one month history of thirst and polyuria, and diabetes mellitus was confirmed by a random plasma glucose of 20 mmol/L. Dietary advice was given and gliclazide (80 mg twice-daily) prescribed. The hyperglycaemic symptoms resolved within two weeks. One year later the gliclazide dose was increased to 160 mg twice-daily because of inadequate glycaemic control and, after a further six months, metformin therapy was introduced and increased to 1 g twice-daily. Some eight months later a random plasma glucose was 26 mmol/L, and glycated haemoglobin 9.7% (n.r. 5.0‐6.2%), therefore insulin therapy was commenced with Human Mixtard 30/70 insulin twice-daily. Glycaemic control improved and four months later the glycated haemoglobin level had fallen to 7.4%. At this stage, the patient complained of intermittent dizzy spells, associated with exertion. Palpitations were not noticed. The home blood glucose monitoring showed pre-meal values of 4‐5 mmol/L, pulse rate was 80 per minute and regular, and blood pressure was 130/80 mmHg both lying and standing. No cardiac murmurs were heard on auscultation and there were no features of peripheral or autonomic neuropathy. The patient was on no medication other than insulin. It was felt hypoglycaemia might be a cause of these dizzy episodes and the insulin dose was reduced, thus the tight glycaemic control eased to allow preprandial glucose values of 7‐9 mmol/L. Nethertheless the exertional dizziness continued and on two occasions there was apparent syncope with spontaneous recovery without glucagon or intravenous glucose being required. A 24-hour cardiac monitor tape showed no heart block or arrhythmia. However, a transthoracic echocardiogram showed a large left atrial myxoma which was confirmed by transoesophageal echocardiogram which showed the left atrial myxoma was attached to the interatrial septum by a long stalk. The myxoma was successfully removed under cardiopulmonary bypass (figure 1). Some sevenyears later, the patient remains free of dizziness and syncope. His glycaemic control continues to be satisfactory with a glycated haemoglobin of 7.2%. Cardiac tumours are rare. The commonest is the myxoma which occurs most frequently in the left atrium and is usually attached, as in this case, to the atrial septum. Because its position may vary with posture, transient or complete obstruction of the mitral valve may occur leading to dizziness or syncope. Variable mitral systolic and diastolic murmurs may be heard but are not always present. The diagnosis is established readily by echocardiography. In a tightly controlled insulin-requiring diabetic subject, it is not unreasonable to suspect dizziness and light-headedness, and even blackouts may be due to hypoglycaemia with neuroglycopenia. In older subjects adrenergic ‘warning symptoms’ may not be present. However, it is important to consider the possibility of other non-hypoglycaemic causes. These might be diabetic in nature e.g. postural hypotension due to autonomic neuropathy where a systolic fall of blood pressure of 20‐30 mmHg will produce syncopal type symptoms. Alternatively, cerebrovascular or cardiovascular factors are more often seen in diabetic subjects at an earlier age. Vertebro-basilar insufficiency or abnormalities of cardiac rate or rhythm (Stokes-Adams attacks) are other possibilities. Twenty-four hour or even 48-hour continuous cardiac monitoring may be helpful in diagnosing the latter. Finally, rarer cases of cardiac syncope may need to be considered. In the case presented, the left atrial myxoma was readily diagnosed by echocardiography and the patient cured by successful cardiac surgery.

Transcranial sonography and vertebrobasilar insufficiency

Objective: The objective was to discuss a case illustrating the role of transcranial Doppler sonography in the screening and treatment of a patient with intermittent vertebral artery brainstem ischemia. Clinical Features: A 28-year-old woman had neck pain, arm pain, headaches, and dizziness. Her symptoms occurred intermittently over several years. Past care had provided little relief. De Kleyn's test, transcranial Doppler sonography, and magnetic resonance imaging/magnetic resonance angiography helped establish a diagnosis of vertebrobasilar syndrome. Intervention and Outcome: The patient was referred for neurosurgical evaluation. She subsequently chose to be treated with spinal manipulative therapy. Her neck pain, headaches, and radicular symptoms resolved. The dizzy spells abated to a tolerable level. The neurosurgeon subsequently re-evaluated the patient and recommended that surgery not be performed. Conclusions: This illustrates a case of extra-arterial mechanical compression of the vertebral arteries documented by transcranial Doppler sonography procedures. Brainstem symptoms were correlated with a documented perfusion deficit during cervical positional testing. This case also demonstrated that spinal manipulative therapy may be safely used on patients with vertebrobasilar insufficiency when the biomechanics and related flow studies are elucidated.