VERTIGO Flashcards
(27 cards)
What features could be consistent with BPPV?
20-30 seconds of vertigo, precipitated by head movement
NO nystagmus at rest i.e. not constant
NO hearing loss
Which canal is usually affected by BPPV?
Anterior canal
What features could be consistent with vestibular neuritis?
Constant vertigo with nystagmus at rest, worsened by head movement
NO new hearing loss
When performing the dix-hallpike manouevre what findings should occur?
Vertical + rotatory nystagmus toward the downward ear
Dix-Hallpike can be positive bilaterally if bilateral anterior semicircular canals are affected
What manouevre should follow a positive dix hallpike test?
Epleys
Resolution or significant improvement of symptoms confirms diagnosis
What examination can be used to aid in distinguishing the cause in constant vertigo with nystagmus?
HINTS plus exam
“Plus” refers to the addition of assessment for new hearing loss
What has to present at rest to perform the HINTS?
Nystagmus!
Can’t be used otherwise
What features should be screened prior to the HINTS which may indicate workup for central veritgo regardless of findings?
New Significant headache or neck pain (vertebral artery dissection/cerebellar bleed)
Focal weakness or paresthesias
Any dangerous D’s - diplopia, dysarthria, dysmetria, dysphonia, dysphagia
Vertical nystagmus at rest (not during the Dix-Hallpike test)
Inability to walk unaided
What are the two most important causes of constant nystagmus and vertigo in the ED?
Vestibular neuritis (majority)
Posterior circulation stroke
BPPV should be causing intermittent vertigo
What is the implication of patient having constant vertigo and ABCD2 score of 4 or more?
50% will have an ischaemic lesion on MRI brain on follow up
Peter Johns references this german paper
What is the ABCD2 score?
The ABCD2 score was developed in the outpatient setting for predicting 7 day risk of a subsequent after a TIA
A score of 0-2 had <1% risk
IT PERFORMS POORLY WHEN USED IN THE EMERGENCY DEPARTMENT
it mayyy be an adjunct in determining whether someone can have outpatient vs in hospital workup
Age >59
BP 140/90 or higher
Other symptoms | speech disturbance | unilat weakness
Duration
History of diabetes
What is fixation on lateral gaze?
Fixation is looking at an object, in lateral gaze this can mask nystagmus!
If you place a piece of paper between patient and wall and ask them to look at the wall as if the paper wasn’t there it can unmask nystagmus!!
What kind of nystagmus would be reassurring in suspected vestibular neuritis?
UNIDIRECTIONAL NYSTAGMUS
The patient will have nystagmus at rest looking forward
The “fast component” will be in one direction
When the patient looks to THAT side it will worsen
When they look the opposite way it will improve and the “fast” component will still be in the same direction
What would be a worrying type of nystagmus?
BIDIRECTIONAL NYSTAGMUS
NB THIS DOES NOT MEAN THERE IS JUST NYSTAGMUS ON BOTH LATERAL GAZES -> IT IS A CHANGE IN THE DIRECTION OF THE FAST COMPONENT i.e. beating right on rightward gaze and beating left on leftward gaze
What is the test of vertical skew?
Cover each eye with your hand interchangeably and look for a vertical movement of the eye when it’s uncovered
What is the implication of vertical skew?
Abnormal and concerning for a central cause
Central causes can be acute e.g. posterior circ stroke, cerebellar bleed or can be subacute with intracranial masses
What is the head impulse test?
Hold onto the skull with patients neck relaxed
Move left and right and swiftly back to the centre
Looking for a CORRECTIVE SAACADE
This ABNORMAL finding is a GOOD finding as it indicates vestibular neuritis
With head impulse its normal to get a few beats of nystagmus
What is a reassuring HINTS?
Must have all 4 without red flags:
Unidirectional nystagmus ONLY
Negative test of skew
Positive head impulse test
NO new hearing loss
RED FLAGS:
New Significant headache or neck pain (vertebral artery dissection/cerebellar bleed)
New hearing loss
Focal weakness or paresthesias
Any dangerous D’s - diplopia, dysarthria, dysmetria, dysphonia, dysphagia
Vertical nystagmus at rest (not during the Dix-Hallpike test)
Which patients should get a HINTS exam?
Patients with hours to days of constant vertigo
Which patients should get a Dix-Hallpike manouevre +/- Epleys if positive
Patients with intermittent vertigo lasting seconds to a minute who
DO NOT have nystagmus at rest
Which patients should get a HINTS and a dix-hallpike?
No patient ever
Which diagnoses do HINTS and dix-hallpike not lead to a diagnosis of?
Vestibular migraine (common)
Menieres disease
MS
Perilymph fistula
Superior canal dehiscence
These diagnoses are not as time sensitive
What features are consistent with a vestibular migraine?
A history of >5 episodes vertigo
Any pre- or post- vertiginous: photophobia/phonobia/visual aura/headache of any degree
If any of the above was present 50% or more of the episodes of vertigo -> consistent with vestibular migraine
Obviously need to consider stroke risk factors
What is the supine roll test?
Dix-hallpike can be negative due to Lateral Canal BPPV
Supine roll test:
* Patient:sitting to a supine position, with the head turned 90 degrees to one side and flexed about 20 degrees foreward
* Once supine, the eyes are typically observed for about 30 seconds. The head is then rotated to the midline for 30 seconds, and then 90 degrees to the other side.
If the person has arthritis in their neck, the maneuver may be performed in side-lying position.
A positive Supine-Roll test consists of a burst of horizontal nystagmus
In lateral canal BPPV, the eyes jump sideways, to opposite directions depending on the side that is down.
As the eyes can either always jump down, or up with respect to gravity, this defines two variants – “geotrophic” nystagmus (down), and “ageotrophic nystagmus” (up). The first is far more common.
