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Dizziness, Double Vision, Nausea, Unsteadiness, Spinning Vertigo, Endpoint Nystagmus, Subclavical Steal Syndrome, On Meclizine, Nortriptyline, Zofran, Lisinopril

Posted on Sat, 29 Sep 2012

Question: Hi Doctor, My daughter is 15 and has been suffering from dizziness, double vision, nausea, and unsteadiness since Feb 18th 2011. Initially it started as room spinning vertigo and nausea, but the vertigo has changed to a chronic contant dizziness and double vision. We've been to (3) ENT's, (2) Neurologists, (1) Neuro-Opthamologist, (2)Vestibular rehab Specialists, and Physical Therapy. She has been put on a variety of medications from Meclizine, Nortryptiline, Zofran, Lisinipril. Nothing has helped. She had to withdraw from school...we need help. She's had a series of tests, Auditory tests, MRI of brain, MRA of the brain and Neck and of the IAC (inner auditory canal) which were all norml. Her eye test revealed endpoint nystagmus. She has doublevision (images side by side) every day. She cannot do video games or go to a movie, because the symptoms are exacerbated. I have been doing research and came across Subclavical Steal Syndrome which causes similar symptoms. The PT's who treated her feel that this is coming from her neck in someway. WHen they compress on certain areas, they are able to reproduce her symptoms. Could SSP be it? Do you recommend at this point we got to a vascular doctor? Vestibular rehab has had no effect on her symptoms. Could it be vascular? We need help! Thank you-XXXXXXX

Answered by Dr. Kiran Kumar (3 hours later)

Hi XXXXXXX,

Thanks for your query.

Your child have symptoms suggestive of Vertigo.
You have already undergone a detailed evaluation including MRI of the brain and MR Angiography which are normal. Imaging of the Inner Auditory Canal is also normal. Its unlikely that she will be having any central or vestibular cause for her Vertigo.

Subclavian Sleat Syndrome/Phenomenon usually produces of symptoms of presyncope and syncope. It will usually not cause constant giddyness and there will not be any constant double vision.

You can still go ahead and consult a Vascular Specialist and take an opinion..

Its surprising that after such detailed evaluation, till there is no cause identified for her symptoms.

I can recommended you one more test.
CSF Examination to evaluate for routine as well as VDRL/Oligoclonal Bands.
Did she receive any injections or vaccines prior to start of these symptoms ?

Please get back if you need any further information

Thanks and Regards

Dr Kiran

Above answer was peer-reviewed by : Dr. Raju A.T

Follow up: Dr. Kiran Kumar (1 hour later)

Just a clarifiction. She doesn't have giddiness...she has dizziness, lightheadedness, balance issues/unsteadiness in addition to the double vision.

She did not receive any vaccines or injections in the past few years.

She had the following labs done which were normal except for low levels of D3 (19.1)and B12 (150).

CBC With Differential/Platelet
Comp. Metabolic Panel (14)

Vitamin B12 and Folate
Hemoglobin A1c

Vitamin D, 25-Hydroxy
Thyroid Cascade Profile

Sedimentation Rate-Westergren
Venipuncture

Are there any other blood tests you would recommend? Is B1 (thiamine)indicated by any of the above tests? Could that be a cause?

Also, Would they typically sedate her at a Children's hospital for the CSF Exam?

Thank you. XXXXXXX

Answered by Dr. Kiran Kumar (6 hours later)

Hi XXXXXXX,

Actually there are two category of symptoms.

1. Vertigenous Symptoms - Usually occurs due to involvement of ear or VII craial nerve. It ypically causea dizzyness/giddyness (In medical terminology, both are used interchangeably), nausea and imbalance. Intially her symptoms started as room spinning vertigo and now its more of a constant dizziness.

2. Purely Imbalance with no vertigenous symptoms such dizzyness/giddyness/nausea. This occurs in Cerebellar Lesions. Since you mentioned that her MRI brain was normal, not sure whether it can be the cause.

Some disease can have an autoimmune phenomenon where there ware antibodies which damage our own body tissues. Such a damage may not be apparent in MRI as it occurs as molecular level.

You should consider the following
1. Autoimmune Profile (ANA, RA, XXXXXXX etc)
2. For 15 year old sedation is not necessary for CSF examination unless child is uncooperative
3. B1 deficiency can cause neuropathy. ut its not a common disease. You can get its levels evaluated fr completion.

Vitamin D3 and B12 supplementation should be continued.

Hope this answers your query.

Thanks and Regards

Dr Kiran

Above answer was peer-reviewed by : Dr. Raju A.T