15. A scientific and clinical approach to acute vertigo

Question 1

What is a vestibular symptom?

Answer 1

the feeling that you are moving when you are not

Question 2

What are the two different perceptual mechanisms?

Answer 2

Vestibular-Motion perception = Sensation of motion of SELF or ENVIRONMENT
Seeing environmental motion = oscillopsia (indicates a nystagmus)

Question 3

What is a nystagmus?

Answer 3

an involuntary eye movement. A patient with nystagmus will see the world move even when it is not

Question 4

Why do patients with nystagmus experience oscilopsia?

Answer 4

This is because during voluntary eye movement, the brain suppresses any visual motion signals but because in nystagmus the eye movements are involuntary, the brain does not suppress visual motion and you experience oscillopsia

Question 5

What are some common causes of vertigo diseases?

Answer 5

BPPV – most common 
Vestibular neuritis – inflammation of the vestibular nerve 
Migrainous vertigo 
Stroke 
Mixed (syncope, anxiety etc) 
Menieres's disease (rare)

Question 6

What are the examinations carried out in vertigo?

Answer 6

Look at the eyes, ears and legs
Eyes: gaze, vestibular optic reflex, halpike and fundoscopy
Ears: Otoscopy
Legs: gait (+tandem)

Question 7

What is BPPV and its symptoms?

Answer 7

Commonest cause of vertigo
Arises from a problem in the inner ear
Can be positional such as when lying in bed
If they turn over in bed and get dizzy they have BPPV as there is no postural change but if they get dizzy only when they stand up then it could be postural hypotension
The side they turn to that makes them feel dizzy is the side with BBPV

Question 8

What is vestibular neuritis and how does it present?

Answer 8

Infection of the vestibular nerve in the inner ear (only the vestibular part of the 8th cranial nerve) 
Subacute onset (minutes – hours) 
Continuous vertigo 
Obvious ‘vestibular’ nystagmus 
Positive head impulse test 
Normal gait

Question 9

What is the treatment for vestibular neuritis?

Answer 9

Vestibular sedatives for 24-36 hours
Mobilise at day 3
Treat any BPPV or migraine

Question 10

What are some red flags for patients presenting with acute vertigo?

Answer 10

Headache - 40% posterior circulation stroke.
Gait ataxia – may be only non-vertiginous manifestation of cerebellar stroke.
Hyperacute onset – suggests vascular origin.
Vertigo + hearing loss – AICA blockage (branch of this artery supplies the labyrinth and the cochlear) or urgent ENT problem.
Prolonged symptoms (> 4 days) – Floor of 4th ventricle problem.