Balance

Question 1

Determiners of balance

Answer 1

Vision
Vestibular system
Proprioception
Cerebellar modulation and integration - downward control

Question 1

What can cause ataxia

Answer 1

Peripheral loss of proprioception or cerebellar problems

Question 2

Causes of vertigo anatomical

Answer 2

Vestibular system, cerebrum or cerebrellum

Question 3

History PC for inbalance

Answer 3

• 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

Question 4

What is nystagmus

Answer 4

Uncontrolled eye movement on saccadic (sudden directional) movement

Question 5

Causes of Nystagmus

Answer 5

BPPV
Vestibular neuronitis
Central cause

Question 6

What type of nystagmus does BPPV cause

Answer 6

Vertical up-down and torsional on dix-hallpike

Question 7

What nystagmus type does vestibular neuronitis cause

Answer 7

L-R nystagmus - gaze worse AWAY from affected side

Question 8

Central cause nystagmus type

Answer 8

Gaze - evoked - no obvious unilateral componenet
Midbrain - also vertical

Question 9

Dix hallpike test

Answer 9

****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

Question 10

Head impulse test

Answer 10

• 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

Question 11

What is unterberger test

Answer 11

Walk in place with eyes closd
More than 30 degrees rotation = asymmetrical labyrinth funciton

Question 12

HINTS test consists of

Answer 12

Head impulse
Nystagmus
Test of skew

Question 13

Who d you perfrom the HINTS test on

Answer 13

Persistent vertigo hours or days
Nystagmus
Normal full neuro exam

Question 14

What does flocculonodular lobe damage cause type of ataxia

Answer 14

Postural instability and nystagmus

Question 15

Vermis damage lobe what type of ataxia

Answer 15

Truncal or gait ataxia

Question 16

Hemisphere damage type of ataxia cause

Answer 16

Dysmetria, intention tremor, dysdiadochokinesia and slurred, staccato speech

Question 17

DANISH symtpoms (cerebellar)

Answer 17

D - Disdiadochokinesia

A - Ataxic Gait (Broad-based)

N- Nystagmus

I - Intention Tremor

S - Slurred speech

H - Hypotonia

Question 18

What is sponteanous vestibular prooblems

Answer 18

Discrete episodes with no clear trigger eg vestibular migraine, mennieres

Question 19

What o triggered episodic vetibular syndrome look like

Answer 19

Discrete episodes minutes/hours of dizziness precipitated by specific trigger - BPPV, orthostatic hypotension

Question 19

Poste exposure acute vestiibular syndrome

Answer 19

Persistent dizziness - lasting days to weeks history of precipitating event eg vestibular neuronitis, posterior circulation

Question 20

Typical BPPV history

Answer 20

Middle age/older patient
Spinning when turn
Nausea
Nystagmus - vertical torsion on diz hallpike

Question 21

Vestibular neuronitis typical history

Answer 21

Acute inflammation of vestibular system
Spontaneous, acute, no trigger
Constant vertio
Resolves in around a week
Intense ongoing nausea, vomitting

Question 22

Predispsoing factors for vestibular neuorinitis

Answer 22

Preceding viral infections
Prev bacterial CNS infections eg meningitis
Prev chronic otitis media
Choleastoma

Question 23

Investigations for vestibular neuritis

Answer 23

- Horizontal, **unidirectional** nystafgmus - WORSE on gaze AWAY from affected side - + head impulse test

Question 24

What is prochlorperazine used of vestibular

Answer 24

Nausea from vestibular/labyrinthine disorders

Question 25

Management of vestibular neuronitis

Answer 25

Conservative - physio, OT Medical - antiemetics, antihistamines - prochlorperazine, cyclizine Underlying cause treat

Question 26

What condition is betahistine used in

Answer 26

Mennieres

Question 27

How does ondenastron eork

Answer 27

Serotonin receptors

Question 28

What is dexamethasone used in causing inbalance

Answer 28

Space occupying lesions

Question 29

Vestibular neuonitis vs labyrinthitis anatomy

Answer 29

Labyrinthitis involves cochlear therefore causes hearing loss

Question 30

Labyrinthitis management

Answer 30

Corticosteroids for acute hearing loss Prednisolone 60mg OD 10-14 days Taper for 5 days

Question 31

Mennieres symptoms

Answer 31

Attacks Recurrent rotatory vertio Sensorineural hearing loss - gradual low frequency, unilateral Tinnitus Sensation of fullness in affected ear

Question 32

Dagnosis of mennieres

Answer 32

Audiometry - sensorineural hearing loss Pure tone audio, electrocholeography - measure APs generated through sound

Question 33

Side effect of betahistines esp in older

Answer 33

Constiaption

Question 34

Management of mennieres incl social

Answer 34

- Reassure attacks will settle - Reduce salt intake in diet - endolymphatic fluid theory - DVLA - Support groups - Hearing devices - Antiemetics - Severe → IV, may require fluids

Question 35

Surgical management of mennieres

Answer 35

Endolymphatic sac surgery Vestibular nerve dissection Chemical labyrinthecoty - gentamycin (ototoxic)

Question 36

Diagnositc criteria for migraine vestibular

Answer 36

=/>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

Question 37

What migraine features need with at least half of all vestibular episodes for diagnosis of vestibular migraine

Answer 37

- Headahce with at least two of: unilateral, pulsating, moderate or severe pain, aggravation by physical activity - Photophobia + phonophobia - Visual aura

Question 38

How treat vestibular migarine

Answer 38

Like normal migraine; - Avoid triggers - Propanolol for prophylaxis - Triptans for acute attacks

Question 39

Conditions affecting sensory afferent neurons

Answer 39

Diabetes GBS Vasculitis Charcot-marie tooth Chemo - platinum, vinca alkaloids, taxanes Dorsal root ganglion conditions Dorsal column

Question 40

Dorsal root ganglion conditions

Answer 40

sjrogens paraneoplastic syndrome - anti-Hu antibodies

Question 41

Dorsal column conditions causing sensory afferent neurones

Answer 41

B12 deficiency - subacute with degeneration of cord Tabes dorsalis - late neurosyphilis

Question 42

Signs of sensory ataxia

Answer 42

High stepping gait Rombergs positive

Question 43

Investigation for sensory ataxia

Answer 43

Bloods - vasculitis, paraneoplastic, AI MRI - spinal cord problems NC studies

Question 44

MRI of SACD

Answer 44

Hyperintensity on T2 MRI in dorsal section of cord

Question 45

What does nitrus oxide abuse cause neurologically

Answer 45

Functional B12 deficiency Normal blood levels but unable to be used by cells Methionine synthase which uses B12

Question 46

Test for functionl B12 deficiency

Answer 46

Test methylamonic acid and homocysteine levels Elevated

Question 47

Causes of cerebellar ataxia

Answer 47

Stroke - AICA, PICA Alcohol Trauma MS Gluten Neurodegenerative diseases - atypical parkinsonism Genetic condition

Question 48

Genetic conditions

Answer 48

Spinocerebellar ataxias Friedrichs ataxia Ataxia telangiectasia

Question 49

Spinocerebellar ataxias

Answer 49

N-acetyl-leucine Middle age presentation #Cerebellar atrophy

Question 50

What is Friedrichs ataxia

Answer 50

Inherited condition Multiple body systems prolems from childhood/early aduthood

Question 51

Inheritnce of friedrichs ataxia

Answer 51

Autosomal recessive inheritance - fratacin gene on Chr9

Question 52

Symptoms of Friedrichs ataxia

Answer 52

dysarthria, hyporeflexia, hypertrophic CM and conduction defects - ECG/ECHO Scoliosis,diabetes Wlaking aids in 20s Control cardiac issues

Question 53

Inheritance Ataxia telagneictasia

Answer 53

Autosomal recessive ATM gene on Chr 11 Childhood starts

Question 54

Symptoms of ataxia telangiectasia

Answer 54

Oculomotor - problems reading Telangictasia in sclera Immune problems

Question 55

What does ataxia telangiectasia increase the risk of

Answer 55

25% lifetime risk of leukaemia or lymphoma Slow rising alphafetoproteins Cerebellar atrophy