15. Dizziness and Vertigo

Question 1

Acute vestibular syndrome defn

Answer 1

dizziness acute, constant, persists >day, accompanied by n/v, unsteady gait, nystagmus and interolance to head motion

Question 2

What 3 systems are key for equilibrium and awareness of body in relationship to surrounding sx

Answer 2

visual
proprioceptive
vestibular systems

Question 3

What does the vestibular apparatus do?

Answer 3

maintain head position
stabilize head movement

Question 4

What is the vestibular apparatus made up of?

Answer 4

three semicircular canals and two otholithic structures

Question 5

Semicircular canal info

Answer 5

info about movement and angular momentum

Question 6

Utricle info

Answer 6

head tilt and vertical linear accel

Question 7

How to otoliths move in BPPV

Answer 7

freely moving otoliths that are inappropriately located within the semicir- cular canals, as in BPPV, can produce positional vertigo even when the head is currently still if the head had been recently moved.

Question 8

impulse travel from vestibular apparatus to brainstem and cerebellum

Answer 8

acoustic nerve (cranial nerve [CN] VIII), enter the brainstem just below the pons and anterior to the cerebellum, and proceed to the four vestibular nuclei of the brainstem and to the cerebellum

Question 9

From brainstem and cerebellum, impulses travel along which 2 pathways to cause vertigo?

Answer 9

1) MLF
2) vestibulospinal tract

Question 10

When does nystagmus occur?

Answer 10

when syncronhized vestibular info becomes unbalanced

Typically, it results from unilateral vestibular dis- ease, which causes asymmetric stimulation of the medial and lateral rectus muscles of the eye. This unopposed activity causes a slow move- ment of the eyes toward the side of the stimulus, regardless of the direc- tion of deviation of the eyes. The cerebral cortex then corrects for these eye movements and rapidly brings the eyes back to the midline, only to have the process repeated.

Question 11

By convention, the direction of nystagmus is denoted by the direction of the ?“cortical” component.

Answer 11

fast

Question 12

Vertebrobasilar insufficiency defn

Answer 12

emporary set of symptoms due to ischemia in the posterior circulation of the brain, which supplies the medulla, pons, midbrain, and cerebellum. M

Question 13

BPPV pathophysiology

Answer 13

Otoliths inappropriately displaced from utricle into semicircular canals (posterior > horizontal > anterior)

Question 14

Vestibular neuritis and labrynthitis pathophys

Answer 14

inflamm/possibly viral of vestibular nerve

Question 15

Meniere disease pathophys

Answer 15

endolymphatic hydrops/excess endolymph in inne ear

Question 16

Perilymph fistula pathophys

Answer 16

abnormal opening btwn middle and inner ear

Question 17

DDX peripheral vertigo

Answer 17

bppv
vestibular neuritis and labrynthitis
meniere disease
perilymph fistula

Question 18

DDX of dizziness into 3 categories - what are they?

Answer 18

acute severe - vestibular neuritis, stroke
recurrent attacks: Meiniere, tia
recurrent positional: bppv, cerebellar tumor, ms

Question 19

ddx timing and triggers approach 3 categories -defn

Answer 19

1. ac vestibular: bestibular neuritis, cerebellar stroke
2. spont episodic vestibular syndrome - meniere disease, vbi
3. triggered episodic vestibular syndrome - bppv

Question 20

vertigo defn

Answer 20

spining sens

Question 21

triad meniere disease

Answer 21

hearing loss
vertigo
tinnitus

Question 22

Peripheral causes of vertigo - list 8

Answer 22

Benign paroxysmal positional vertigo (BPPV) Vestibular neuritis (or neuronitis)/labyrinthitis Ménière disease
Foreign body in ear canal
Acute otitis media Perilymphatic fistula
Trauma (labyrinth concussion) Motion sickness
Acoustic neuroma

Question 23

central causes of vertigo

Answer 23

Vertebral basilar artery insufficiency Cerebellar hemorrhage or infarction Tumor
Migrainous vertigo
Multiple sclerosis
Posttraumatic injury (temporal bone fracture, postconcussive syndrome) Infection (encephalitis, meningitis, brain abscess)
Temporal lobe epilepsy
Subclavian steal syndrome

Question 24

BPPV hx

Answer 24

Short-lived (typically <30 s), positional, fatigable episodes; more often in older adults.

Question 25

Name 5 medications causing vestibulotoxicity

Answer 25

(e.g., aminogly- cosides, anticonvulsants, alcohols, quinine, quinidine, and minocy- cline

Question 26

Subclavian steal syndrome PE

Answer 26

When subclavian steal syndrome is suspected, which also can cause VBI, the pulse and blood pressure should be checked in both extremities. A difference in blood pressure of greater than 40 mm Hg from one arm to the other is concerning for subclavian steal syndrome, and the patient will likely have arm fatigue or other symptoms on the affected side.

Question 27

Vesibular neuritis/labrynthitis hx

Answer 27

Vertigo may develop suddenly or evolve over several hours, usually increasing in intensity for hours, then gradually subsiding over several days but can last weeks. Can be worsened with positional change. Sometimes history of viral infection precedes initial attack. Highest incidence is found in third and fifth decades.

Question 28

What is Wallenberg syndrome?

Answer 28

occlusion of PICA: vertigo associated with significant neuro complaints n/v, loss of pain and temp sensation on side face ipsi to lesion and opp side obdy parlysis palate, pharynx, larynx Horner syndrome (ipsi ptosis, miosis, decr facial sweat)

Question 29

Peripheral vs central vertigo: onset

Answer 29

sudden gradual

Question 30

Peripheral vs central vertigo: intensity

Answer 30

severe initial, then decr over time mild in most bu can be sev in stroke and ms

Question 31

Peripheral vs central vertigo: duration

Answer 31

intermittent episodes lasting seconds to less than min for bppv/cont long for vestibular neuritis wk, months cont but can s-mins with vascular causes such as with posterior circulation tia

Question 32

Peripheral vs central vertigo: direction of nystagmus

Answer 32

torsional, upbeat in classic posterior canal bppv or horiz bppv/vestibular neuritis/labrynthitis vertical, spont and torsional, direction changing on lat gaze, downbeating

Question 33

Peripheral vs central vertigo: effect of head pos

Answer 33

induces vertigo (bppv), worsens vertigo )vestibular neuritis) little change but can worsen with position cange

Question 34

Peripheral vs central vertigo: assoc neuro findings

Answer 34

none usually present

Question 35

Peripheral vs central vertigo: assoc auditory findings

Answer 35

present possible, including tinnitus 9meniere) and hearing loss (labrynthitis) rare

Question 36

Internuclear opthalmoplegia defn

Answer 36

indi- cates brainstem pathology, is recognized when the eyes are in a normal position on straight-ahead gaze, but on eye movement the adducting eye (CN III) is weak or shows no movement while the abducting eye (CN VI) moves normally (although often displaying a coarse nystag- mus). This finding indicates an interruption of the MLF on the side that demonstrates third CN weakness and is virtually pathognomonic of multiple sclerosis.

Question 37

Cerebellar tests

Answer 37

dysmetric finger to nose dysdiadochokinesia -rapid alternating movements ataxic gait nystagmus

Question 38

How to test midline cerebellum lesions?

Answer 38

truncal ataxia sit to stand to walk unaided

Question 39

Dix Hallpike test

Answer 39

only for bppv/triggered turns the patient’s head 45 degrees to one side and then moves the patient from the upright seated position to a supine position with the head overhanging the edge of the gurney (Fig. 15.1). The patient is que- ried for the occurrence of vertigo, and the eyes are observed for nys- tagmus after a latency period of a few seconds. In a patient with classic posterior canal BPPV, the nystagmus usually lasts 5 to 30 seconds and is combined upbeating (the fast phase beats toward the forehead) and ipsilateral torsional (the top pole beating toward the downward ear). The patient is then brought back up to the seated position, and the test is repeated with the head turned 45 degrees to the other side

Question 40

Classic findings during dx hallpike test in posterior canal bppv

Answer 40

Latency (delay in nystagmus and vertigo once in head-hanging position) of approximately 3–10 s, although delay can take up to 30 s on rare occasions Reproduction of vertigo symptoms in head-hanging position Upbeat (fast phase toward forehead) and torsional nystagmus (usually toward the downward ear) Vertigo and nystagmus escalate in head-hanging position, then slowly resolve over 5–30 s Nystagmus and vertigo may reverse direction when patient returns to sitting position Nystagmus and vertigo decrease with repeated testing (fatigability)

Question 41

If dix hallpike +, epley menuever - how to perform?

Answer 41

The first step of the Epley maneuver is the first part of the Hallpike test, which involves turning the head 45 degrees to the involved side and then laying the patient with the head hanging over the edge of the gurney.)

Question 42

HINTS exam - what does this entail?

Answer 42

HINTS (Head Impulse test, Nystagmus, Test of Skew) is a bedside oculomotor examination test that has been proposed as a way to differentiate central from peripheral vertigo in patients with acute vestibular syndrome. - head impulse test nystagmus test of skew

Question 43

What is the head impulse test

Answer 43

corrective saccade indicates a positive test and is more reas- suring for vestibular neuritis, which is a benign cause of vertigo.

Question 44

Nystagmus: of hints test - peripheral vs central

Answer 44

non horizontal = concern central (changing, vertical, torsional)

Question 45

Test of skew findings

Answer 45

The third part (test of skew) refers to vertical ocular misalignment during alternate cover testing, and its presence is suggestive of brainstem strokes.

Question 46

BPPV vs vestibular neuritis/labrynthitis: age

Answer 46

older yo

Question 47

BPPV vs vestibular neuritis/labrynthitis: hearing loss

Answer 47

none none in vestib neur/hearing loss

Question 48

BPPV vs vestibular neuritis/labrynthitis: freq sx

Answer 48

episodic constant

Question 49

BPPV vs vestibular neuritis/labrynthitis: hallpike test

Answer 49

+ worse in head hang but really shouldn't do

Question 50

BPPV vs vestibular neuritis/labrynthitis: head impulse test

Answer 50

neg +

Question 51

BPPV vs vestibular neuritis/labrynthitis: epley

Answer 51

highly effective ineff

Question 52

BPPV vs vestibular neuritis/labrynthitis: recurrence

Answer 52

freq rare

Question 53

Barbeque roll tx for BPPV

Answer 53

horizontal canal variant of BPPV patient lies flat on the gurney with the head turned 90 degrees to the involved side. The head is then rotated in 45-degree intervals away from the involved side (each turn is held approximately 30 seconds or until nystagmus and vertigo resolve). Eventually the patient needs to turn over into the prone position

Question 54

Vestibular neuritis inflamm of which nerve?

Answer 54

CN8

Question 55

A patient presents to the emergency department with dizziness and is diagnosed with horizontal canal benign paroxysmal posi- tional vertigo (BPPV). What maneuver can be used to treat the patient? a. Barbecueroll b. Epley maneuver c. Hallpiketest d. Head impulse test

Answer 55

a b- epley tx posterior

Question 56

A 70-year-old woman presents with a first ever episode of severe ver- tigo. Which of the following examination findings should prompt the physician to order imaging tests and/or consultation with a neurolo- gist? a. Direction changing nystagmus on change in head position b. Direction changing nystagmus on change in lateral gaze c. Positive head impulse test d. Torsional upbeat nystagmus during Hallpike test

Answer 56

b

Question 57

Internuclear ophthalmoplegia most often suggests a diagnosis of which of the following conditions? a. Horizontal canal benign paroxysmal positional vertigo (BPPV) b. Labyrinthitis c. Multiplesclerosis d. Vestibular neuritis

Answer 57

c

Question 58

Which of the following is a central cause of vertigo? a. Labyrinthitis b. Ménière disease c. Vertebrobasilarinsufficiency d. Vestibular neuritis

Answer 58

c

Question 59

Continuous vertigo of what duration is used to define acute vestib- ular syndrome? a. 1hour b. 8 hours c. 24hours d. 1 week

Answer 59

c

Question 60

First steps of management algorithm for dizziness and vertigo:

Answer 60

medical cause w/u: ecg, glucose, hbg, bun/cr, review meds vs persistent sx - HINTS/focal neuro finding/can't sit or walk vs triggered: hallpike/supine roll/orthost vitals vs spont sx: assess for tia vs vestibular migraine vs meniere disease

Question 61

assess for tia vs vestibular migraine vs meniere disease - what are RF?

Answer 61

age previous stroke abn gait focal neuro findings complaint instability hx vascualr disease

Question 62

Name 5 meds you can give in acute vertigo

Answer 62

ondans dimenhydrainate metovlopromide scopolamine diazepam