Case histories Flashcards
What is third degree left nystagmus
Eye in the left, middle and right position- will show a left beat
Explain the answer for case 1 in the vertigo lecture
A: The head impulse test is positive to the right.
E: We know the patient has 3rd degree left nystagmus- eye beating to the left- so peripheral
CN8 has tone on each eye
When you remove this nerve from one eye, we have unopposed tone of the same nerve on the opposite side- so the eye will droop to the weaker side (like in Bell’s palsy).
So if CN8 on the right eye is damaged- eyes will droop towards right (slow drift) and show fast drift towards left
What is vertigo and hearing loss a red flag for and why
Occlusion of the left internal auditory artery could explain this presentation.
This us a branch of the anterior inferior cerebellar artery
A 65 year old artist with hypertension has a 4 year history of recurrent attacks of violent spinning dizziness with sweating, a sensation of impending doom and nausea. He feels unwell for about an hour afterwards. The attacks occur on looking up. On direct questioning the attacks also occur in bed.
What one test would you perform to do to confirm the diagnosis
C. Hallpike manoeuvre (for BPPV)
What is head tilt and vertigo a red flag for
Stroke
Ocular tilt reaction- due to destruction of otolithic pathways
Tilt direction towards the weak side
Acute isolated vertigo on waking up + imbalance
What is the likely cause
A left medullary lesion could explain the symptoms and signs.
Three episodes over the past 6 weeks lasting 2-4 hrs with: Sensation she is spinning (merry-go-round) and seeing the room spin to her left. Has to sleep it off. Past 6 months Buzzing central tinnitus with normal hearing. Weekly mild rocking-boat self-motion sensation lasting hours. Frequent stress-headaches in her 20’s, now x4/yr. Normal exam when well but during vertigo attacks has left horizontal gaze-evoked nystagmus.
Which of the following is true
The recurrent nature is more reassuring than if this was a first presentation.
Likely to be meningitis- hearing is spared!! and it is recurrent
50-year old surgeon. • Showering after flight from Sydney to London. Reached down to pick up soap and on standing instant severe spinning dizziness, vomiting, severe occipital headache. • Next day saw family doctor who prescribed some pills. • Two days later still unwell and seen in the emergency room. • Severe vertigo, nausea, occipital headache. • Examination - no nystagmus and a normal head impulse test. Unable to sit on the side of the bed without being held up.
Which of the following is true?
Not peripheral in nature- head impulse test normal
Could be acute migraine
Could be acute cerebellar stroke- not involving the brainstem- won’t show on CT- could be a result of DVT- normally these patients can’t walk
Acute brain imaging is indicated- MRI confirms diagnossi of acute cerebellar stroke
What can present with projectile refractory vomiting
Abnormality in the floor of the fourth ventricle- best treatment is treatment for space sickness- scopolamine and dexamphetamine
Define dizziness, vertigo and oscillopsia; recognise how these conditions differ
Define dizziness – An illusion of self- and/or environmental motion
Define vertigo (a subset of dizziness) – Illusory selfmotion which is spinning in nature
Define oscillopsia – Visual world motion
Recognise how oscillopsia differs from vertigo – Vertigo is present even with one’s eyes shut
Relate the anatomy to the causes of acute vertigo
Anatomy of vertigo – Ear-peripheral vestibular apparatus or vestibular nerve Subcortical-cerebellum,vestibular nuclei (pontomedullary junction) o cerebral cortex-temporal and parietal cortex
Pathophysiology of vertigo – Ear–vestibular neuritis,Meniere’s disease Subcortical–stroke(brain stem or cerebellar stroke), migraine
Cortical–epilepsy,migraine
List the most common causes of acute vertigo
Causes of acute vertigo and frequency
Very common–BPPV
Common–migraine, postural hypotension
Occasional–vestibular neuritis,cerebellar stroke or brainstem stroke o Rare–Meniere’s disease
Very rare–vestibular paroxysmia, vestibular epilepsy
Summarise the treatment for acute vertigo
Therapy
BPPV–Particle repositioning manoeuvre
Migraine–acute:aspirin;chronic:prophylaxis(e.g.betablocker).
Vestibular neuritis–self-limiting;supportive then mobilization.
Finally, the 3 commonest causes of vertigo in A&E are BPPV, BPPV & BPPV
