Balance Flashcards
Determiners of balance
Vision
Vestibular system
Proprioception
Cerebellar modulation and integration - downward control
What can cause ataxia
Peripheral loss of proprioception or cerebellar problems
Causes of vertigo anatomical
Vestibular system, cerebrum or cerebrellum
History PC for inbalance
- Onset - when, triggers, how long takes
- Chronicity = come and go, persistent, attacks how long, space between
- Ass symptoms - headache, hearing, vision, motor problems, cognitive problems
What is nystagmus
Uncontrolled eye movement on saccadic (sudden directional) movement
Causes of Nystagmus
BPPV
Vestibular neuronitis
Central cause
What type of nystagmus does BPPV cause
Vertical up-down and torsional on dix-hallpike
What nystagmus type does vestibular neuronitis cause
L-R nystagmus - gaze worse AWAY from affected side
Central cause nystagmus type
Gaze - evoked - no obvious unilateral componenet
Midbrain - also vertical
Dix hallpike test
****ix hallpike manouvere****
- Turn head 45 degrees towards and observe eyes for 30s, lowered back so head 20 degrees over back of couch
- Stay there for 1 minute
- See nystagmus in 20-30s
- Perform on both sides - side thats asymptomatic
Head impulse test
- Corrective saccade on fast movement
- Diagnose peripheral vestibular vertigo
- Rapid jerk 10-20 degrees one direction, slow to centre repeat other way
- Ask to look at nose
- Normal = eyes stay fixed. normal or central cause
- Abnormal = eyes saccade - rapid side to side movement
What is unterberger test
Walk in place with eyes closd
More than 30 degrees rotation = asymmetrical labyrinth funciton
HINTS test consists of
Head impulse
Nystagmus
Test of skew
Who d you perfrom the HINTS test on
Persistent vertigo hours or days
Nystagmus
Normal full neuro exam
What does flocculonodular lobe damage cause type of ataxia
Postural instability and nystagmus
Vermis damage lobe what type of ataxia
Truncal or gait ataxia
Hemisphere damage type of ataxia cause
Dysmetria, intention tremor, dysdiadochokinesia and slurred, staccato speech
DANISH symtpoms (cerebellar)
D - Disdiadochokinesia
A - Ataxic Gait (Broad-based)
N- Nystagmus
I - Intention Tremor
S - Slurred speech
H - Hypotonia
What is sponteanous vestibular prooblems
Discrete episodes with no clear trigger eg vestibular migraine, mennieres
What o triggered episodic vetibular syndrome look like
Discrete episodes minutes/hours of dizziness precipitated by specific trigger - BPPV, orthostatic hypotension
Poste exposure acute vestiibular syndrome
Persistent dizziness - lasting days to weeks history of precipitating event eg vestibular neuronitis, posterior circulation
Typical BPPV history
Middle age/older patient
Spinning when turn
Nausea
Nystagmus - vertical torsion on diz hallpike
Vestibular neuronitis typical history
Acute inflammation of vestibular system
Spontaneous, acute, no trigger
Constant vertio
Resolves in around a week
Intense ongoing nausea, vomitting
Predispsoing factors for vestibular neuorinitis
Preceding viral infections
Prev bacterial CNS infections eg meningitis
Prev chronic otitis media
Choleastoma
Investigations for vestibular neuritis
- Horizontal, unidirectional nystafgmus
- WORSE on gaze AWAY from affected side
- head impulse test
What is prochlorperazine used of vestibular
Nausea from vestibular/labyrinthine disorders
Management of vestibular neuronitis
Conservative - physio, OT
Medical - antiemetics, antihistamines - prochlorperazine, cyclizine
Underlying cause treat
What condition is betahistine used in
Mennieres
How does ondenastron eork
Serotonin receptors
What is dexamethasone used in causing inbalance
Space occupying lesions
Vestibular neuonitis vs labyrinthitis anatomy
Labyrinthitis involves cochlear therefore causes hearing loss
Labyrinthitis management
Corticosteroids for acute hearing loss
Prednisolone 60mg OD 10-14 days
Taper for 5 days
Mennieres symptoms
Attacks Recurrent rotatory vertio
Sensorineural hearing loss - gradual low frequency, unilateral
Tinnitus
Sensation of fullness in affected ear
Dagnosis of mennieres
Audiometry - sensorineural hearing loss
Pure tone audio, electrocholeography - measure APs generated through sound
Side effect of betahistines esp in older
Constiaption
Management of mennieres incl social
- Reassure attacks will settle
- Reduce salt intake in diet - endolymphatic fluid theory
- DVLA
- Support groups
- Hearing devices
- Antiemetics
- Severe → IV, may require fluids
Surgical management of mennieres
Endolymphatic sac surgery
Vestibular nerve dissection
Chemical labyrinthecoty - gentamycin (ototoxic)
Diagnositc criteria for migraine vestibular
=/>5 episodes vestibular symptoms mod/sev, 5 mins - 72 hours
Current or prev history migraine with or without aura
One or more migraine features with at least half of all vestibular episodes
What migraine features need with at least half of all vestibular episodes for diagnosis of vestibular migraine
- Headahce with at least two of: unilateral, pulsating, moderate or severe pain, aggravation by physical activity
- Photophobia + phonophobia
- Visual aura
How treat vestibular migarine
Like normal migraine;
- Avoid triggers
- Propanolol for prophylaxis
- Triptans for acute attacks
Conditions affecting sensory afferent neurons
Diabetes
GBS
Vasculitis
Charcot-marie tooth
Chemo - platinum, vinca alkaloids, taxanes
Dorsal root ganglion conditions
Dorsal column
Dorsal root ganglion conditions
sjrogens
paraneoplastic syndrome - anti-Hu antibodies
Dorsal column conditions causing sensory afferent neurones
B12 deficiency - subacute with degeneration of cord
Tabes dorsalis - late neurosyphilis
Signs of sensory ataxia
High stepping gait
Rombergs positive
Investigation for sensory ataxia
Bloods - vasculitis, paraneoplastic, AI
MRI - spinal cord problems
NC studies
MRI of SACD
Hyperintensity on T2 MRI in dorsal section of cord
What does nitrus oxide abuse cause neurologically
Functional B12 deficiency
Normal blood levels but unable to be used by cells
Methionine synthase which uses B12
Test for functionl B12 deficiency
Test methylamonic acid and homocysteine levels
Elevated
Causes of cerebellar ataxia
Stroke - AICA, PICA
Alcohol
Trauma
MS
Gluten
Neurodegenerative diseases - atypical parkinsonism
Genetic condition
Genetic conditions
Spinocerebellar ataxias
Friedrichs ataxia
Ataxia telangiectasia
Spinocerebellar ataxias
N-acetyl-leucine
Middle age presentation
#Cerebellar atrophy
What is Friedrichs ataxia
Inherited condition Multiple body systems prolems from childhood/early aduthood
Inheritnce of friedrichs ataxia
Autosomal recessive inheritance - fratacin gene on Chr9
Symptoms of Friedrichs ataxia
dysarthria, hyporeflexia, hypertrophic CM and conduction defects - ECG/ECHO
Scoliosis,diabetes
Wlaking aids in 20s
Control cardiac issues
Inheritance Ataxia telagneictasia
Autosomal recessive ATM gene on Chr 11
Childhood starts
Symptoms of ataxia telangiectasia
Oculomotor - problems reading
Telangictasia in sclera
Immune problems
What does ataxia telangiectasia increase the risk of
25% lifetime risk of leukaemia or lymphoma
Slow rising alphafetoproteins
Cerebellar atrophy
