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Vertigo is defined as the illusion of internal or external motion. The evaluation of a patient with vertigo in the primary care setting should not necessarily focus on providing a specific diagnosis. Rather, the physician should aim to localize the lesion. This practice streamlines the workup of patients. This article provides detailed information regarding appropriate organ system-based clinical history and the clinical workup of vertigo. Additional signs and symptoms that can facilitate appropriate referral and treatment are highlighted. Although disorder-specific treatments exist the mainstay of therapy for vertigo-induced pathology is physical therapy.

A focused history, otoscopic and tuning fork examination and formal hearing testing are the diagnostic pillars for the workup of hearing loss and tinnitus. The causes of hearing loss and tinnitus are varied and range from relatively common age-related hearing loss to rare tumors of the brain and skull base. In this chapter, the authors explain the diagnostic workup of hearing loss and tinnitus, review the pathophysiology of the most common causes, and describe the treatments available.

Objective Treatment of ruptured cerebral aneurysms by endovascular coiling is associated with a better neurologic outcome when compared with neurosurgical clipping but has a higher risk for target aneurysm rebleeding after treatment. We hypothesize that aggressive retreatment of coiled aneurysms will lead to fewer recurrent hemorrhages as compared with historical values of 2.3%–3.0%. Methods All first-time Guglielmi detachable coil–embolized cerebral aneurysms were retrospectively reviewed at a single institution from 2004 to 2015. Aneurysm retreatment after first-time embolization was recorded as well as time to retreatment. Retreatment at our institution is routinely performed for incomplete coiling with etiologies including incomplete initial coiling, coil compaction, and aneurysmal dilatation. Aneurysm rerupture was treated with additional coiling. Kaplan-Meier survival analysis was performed to evaluate embolization durability. Results There were 214 aneurysms that met inclusion criteria. Mean (standard deviation) follow-up was 2.74 (2.24) years. Aneurysms that were patent or recanalized were retreated. Mean (standard deviation) time to retreatment was 9 (9) months. Overall, 46 (21.5%) aneurysms required retreatment. Retreatment was performed for coil compaction/remnant growth, recanalization, persistent remnant, and rebleed. Two (0.9%) patients had recurrent aneurysm hemorrhage and both were treated with additional coil embolization. There were no new long-term neurologic deficits caused by aneurysm retreatment. Conclusions Aggressive retreatment of previously ruptured, coiled cerebral aneurysms for persistent aneurysm patency reduces the recurrent hemorrhage risk to that historically seen in neurosurgically clipped aneurysms with minimal additional morbidity. This study validates a large body of literature demonstrating the significance of post-treatment aneurysm remnants and their association with recurrent hemorrhage.

BACKGROUND The fiberoptic intraparenchymal pressure monitor has been shown to provide reliable data in patients monitored for a short period of time. An analysis of a large population, including patients monitored for a prolonged period such as weeks, has never been performed. METHODS We conducted a retrospective study in which we evaluated the fiberoptic intraparenchymal cerebral pressure monitor for complications and accuracy. RESULTS The fiberoptic intraparenchymal cerebral pressure (ICP) monitor was used in 244 patients since 1988. Pathology included trauma in 180, intracerebral hemorrhage (ICH) in 19, aneurysmal subarachnoid hemorrhage in 16, arteriovenous malformations in 10, cerebral edema in 12, and tumor in 7. The mean length of monitoring was 7 days with 49 patients (20%) monitored 1-2 days, 105 (43%) monitored 3-6 days, 48 monitored for 7-10 days (20%), and 42 (17%) monitored from 10-24 days. Seventy-four patients also had ventriculostomies and there was strong correlation with the ICP monitor (p < 0.001). Complications from insertion were 2 patients (0.8%) with ICH, both with hepatic dysfunction. In the group monitored greater than 6 days, 34 patients (38%) required at least one catheter change due to upward drift of the ICP. Fiberoptic breakage requiring replacement was documented in 41 patients (16%). An insertion-site infection occurred in one case monitored for 23 days. Two infected bone flaps occurred that had a monitor placed in the flap. There were no cases of bacterial meningitis or cerebral abscess. CONCLUSIONS The monitor is easy, safe, and reliable to use with a very low rate of infection. Coagulopathic patients may best be monitored by an alternative method.

Thyrotropin-releasing hormone (TRH) and serotonin (5-HT) are well known as neurotransmitters of descending bulbo-spinal tracts. 5-HT uptake caudal to (5-HT decreased) graded spinal lesions has been measured in rats and dogs and significantly correlated with the degree of cord injury. We studied 5-HT content via high-pressure liquid chromatography and radioimmunoassay measurements of TRH in dog spinal cord, both rostral and caudal, to 6 week T6 spinal transection (T) (n = 7) or T6 hemisections (H) (n = 7). Sham controls (n = 7) were used. Mean 5-HT content values were (pmole/mg): rostral sham 1.25 +/- 0.02, caudal sham 1.35 +/- 0.17, rostral T 2.65 +/- 0.36, caudal T 0.19 +/- 0.06, rostral H 2.1 +/- 0.22, and caudal H 1.0 +/- 0.31. A significant decrease in 5-HT caudal to transection versus control (P < 0.001) was seen. A trend for decreased 5-HT caudal to hemisection versus control (P < 0.1) was also seen. Mean TRH levels (pg/mg protein) were: rostral sham 40.02 +/- 18.47, caudal sham 30.61 +/- 10.03, brainstem sham 18.9 +/- 5.13, rostral T 52.4 +/- 21.34, caudal T 3.52 +/- 1.87, brainstem T 19.25 +/- 4.11, rostral H 43.45 +/- 18.61, caudal H 14.24 +/- 5.7, and brainstem H 21.89 +/- 1.23. Significant decreases for caudal TRH transection versus controls (P < 0.001) and for caudal TRH hemisection versus controls (P < 0.02) were seen. A significant difference between caudal hemisection and caudal transection TRH levels (P < 0.001) was seen.(ABSTRACT TRUNCATED AT 250 WORDS)