Week 7 - A 31 year old woman with vertigo Flashcards
What are the principles of assessing a patient with vertigo?
How do you differentiate central from peripheral causes of vertigo? What are
some causes of each?
- 4 Signs suggesting central nervous involvement?
- 6 Examples of central lesions causing vertigo?
- 4 Examples of peripheral causes of vertigo?
How do you interpret this woman’s neurological signs?
Given the probable site of the problem, the patient is referred to a neurologist. Her vertigo had improved but has not resolved completely. Various tests were performed. Name the following investigation and describe the abnormalities?
What is the likely diagnosis and what other tests could be done to further support the diagnosis?
The cerebrospinal fluid showed a moderate elevation of mononuclear cells and protein and was positive for oligocional bands. After the diagnosis is made, the patient returns to see you. Her symptoms have largely resolved. She asks what her prognosis is and if any treatment is available. What is your reply?
Define Vertigo. How does it differ from dizziness? What must you not confuse it with?
Vertigo: the sensation of spinning or swaying of oneself (internal vertigo) or of one’s surroundings (external vertigo) while stationary; caused by vestibular dysfunction due to asymmetric vestibular input and may be spontaneous or triggered.
Dizziness: A nonvertiginous disturbance in spatial orientation without a false sensation of motion
Often used by patients as an umbrella term to describe a variety of sensations, including vertigo, presyncope, imbalance, and confusion.
Do not confuse vertigo for presyncope, which refers to severe lightheadedness or near loss of consciousness; most commonly due to a drop in systemic blood pressure or hypoxia.
List the peripheral and central causes of vertigo?
Clinical features of common causes of vertigo?
Clinical features of Peripheral vs. Central vertigo?
Clinical features of common causes of vertigo?
Describe an approach to the clinical evaluation of a patient presenting with vertigo?
- History?
- Examination?
- Special tests?
Discuss the diagnostic approach to vertigo?
What is the Dix-Hallpike manouever?
A test used to diagnose benign paroxysmal positional vertigo (BPPV) and identify the affected side by provoking an attack.
Characteristic findings
Positive Dix-Hallpike test: positional vertigo and nystagmus triggered during the maneuver
Direction of nystagmus
**Posterior canal BPPV: **upbeat nystagmus with ipsiversive torsional nystagmus component
Anterior canal BPPV: downbeat nystagmus with ipsiversive torsional nystagmus
What is the Head impulse, nystagmus, test of skew (HINTS) examination?
- Indication?
- Objective?
- Next steps?
Head impulse, nystagmus, test of skew (HINTS) examination
Indication: symptomatic patients with acute vestibular syndrome
Objective: to screen for central causes of vertigo, especially stroke
Next steps: If HINTS testing suggests a central cause of vertigo, begin urgent management and obtain neuroimaging.
Discuss the role of neuroimaging in diagnostics for vertigo?
Other than neuroimaging which additional studies should be performed for patients presenting with vertigo?
Discuss the Management of peripheral vertigo?
Management of peripheral vertigo
Identify and treat the underlying condition based on clinical evaluation.
Consider short-term symptomatic pharmacotherapy for acute vertigo, nausea, and vomiting.
- Vestibular suppressants
- Antiemetics, e.g., metoclopramide, ondansetron
Medications for treatment of acute vertigo?
Only use symptomatic treatment for acute vertigo for a short time, while nausea is a problem (usually up to 48 hours). To treat the symptoms of acute vertigo due to vestibular neuritis or other vestibular disorders (eg Ménière disease, vestibular migraine), first-line therapy is prochlorperazine or promethazine.
Define:
- Vestibular neuritis?
- Labyrinthitis?
- Acute peripheral vestibulopathy?
Vestibular neuritis: inflammation of the vestibular nerve with features of vestibular hypofunction, such as vertigo, nausea, vomiting, and gait instability, usually without hearing loss.
Labyrinthitis: ipsilateral sensorineural hearing loss associated with features of vestibular neuritis.
Acute peripheral vestibulopathy: a term used to encompass peripheral causes of acute vestibular syndrome (i.e., vestibular neuritis and labyrinthitis) .
Describe the anatomy of the inner ear.
The inner ear consists of a bony labyrinth with a membranous labyrinth inside it, separated by a space containing perilymph fluid. It contains the cochlea and vestibular system. The cochlea (on the right) is responsible for the conversion of sound waves into neuronal signals, which are transmitted via the cochlear nerve (depicted by a cartoon DJ). The vestibular system (on the left) consists of three semicircular canals, the saccule, and the utricle. Semicircular canals detect angular acceleration in three planes: the superior or anterior semicircular canal in the sagittal plane, the posterior semicircular canal in the coronal plane, and the lateral or horizontal semicircular canal in the transverse plane. The saccule and utricle contain cells that detect linear motion in the vertical and horizontal planes, respectively. The neuronal signals from the semicircular canals are transmitted via the vestibular nerve (depicted by a dancing cartoon).
Epidemiology & Aetiology of Vestibular Neuritis?
Aetiology:
- Idiopathic inflammation of the vestibular nerve
- Tends to occur more often after upper airway infections
Clinical features of Vestibular Neuritis?
Diagnosis of Vestibular Neuritis?
Treatment of Vestibular Neuritis?
Complications and Prognosis of Vestibular Neuritis?
Complications
1. BPPV: In about 10–15% of patients, BPPV develops within weeks of vestibular neuritis onset.
2. Persistent postural perceptual dizziness: fear of falling or unsteadiness without actual falls or vestibular dysfunction to explain the symptoms.
What is Labyrinthitis?
- Definition?
- Epidemiology?
- Aetiology?
- Pathophysiology?
Labyrinthitis
- Clinical features?
- Diagnostics?
- Treatment?
What is Benign paroxysmal positional vertigo (BPPV)?
Episodic vertigo triggered by certain changes in the position of the head.
How can BPPV be classified?
BPPV can be classified into the following subtypes depending on which semicircular canal is involved.
Epidemiology of BPPV?
Aetiology of BPPV?
Although the exact etiology is unknown in most patients with BPPV, the condition is thought to result from the dislodgement or abnormal adherence of otoconia. The etiology of dislodged or adherent otoconia is described here.
Describe the pathophysiology of BPPV?
Clinical features of BPPV?
Approach to the diagnosis of BPPV?
What are the Provoking maneuvers for BPPV?
What are Canalith repositioning maneuvers (CRM)? Example?
Canalith repositioning maneuvers (CRM)
Definition: set of specific sequential maneuvers performed to mobilize the otoconia out of the involved semicircular canal and back into the vestibule
Indication: first-line treatment for BPPV
Outcome
- Up to 80–90% success rate
- Recurrences requiring repeat CRM are expected.
- Canal conversion
Treatment & Prognosis of BPPV?
Prognosis
Spontaneous resolution (with observation alone):
- Approx. 25% at 1 month
- Approx. 50% at 3 months
Recurrence rate: annually around 15%
What is Meniere disease?
- Epidemiology?
Sex: ♀ ≥ ♂
Onset: 20–60 years of age
Peak incidence: 40–50 years
Prevalence: 50–200 in 100,000 individuals in the US
Meniere disease
- Aetiology? (6)
- Pathophysiology?
Aetiology
1. Idiopathic
Several etiologies have been proposed, including:
2. Viral infections
3. Autoimmune disease
4. Inner ear autoimmune disease
5. Systemic autoimmune disease
6. Allergies
Aetiology
1. Idiopathic
Several etiologies have been proposed, including:
2. Viral infections
3. Autoimmune disease
4. Inner ear autoimmune disease
5. Systemic autoimmune disease
6. Allergies
Meniere disease - Clinical features:
- Timecourse?
- Meniere triad?
- Additional symptoms?
- Triggers?
- Progression?
Meniere disease - Diagnostic Criteria?
Meniere disease is diagnosed based on the characteristic clinical features and demonstrable low- to mid-frequency SNHL on audiometry. Specialized tests (e.g., vestibular function testing, electrocochleography) are reserved for patients with atypical symptoms or before attempting ablative therapies. Neuroimaging should be considered if central vertigo is suspected.
Describe the role of Subjective audiometry in the diagnosis of Meniere’s disease?
Discuss the recurrence prevention and maintenance therapy for Meniere’s disease?
Discuss the acute therapy for Meniere’s disease?
There is currently no definitive cure for Meniere disease. Treatment is directed toward symptomatic management and prevention of recurrence. Interventional therapy or surgery is reserved for patients with intractable symptoms that significantly hinder their quality of life.
Discuss the interventional and surgical therapy for Meniere’s disease?
