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NMSK Exam 2: Neuro > Disorders of Equillibrium > Flashcards

Disorders of Equillibrium Flashcards

1
Q

Balance and awareness of body position in relation to surroundings requires input from 2 of the following 3 systems…

A
  1. Visual–to judge distance
  2. Labyrinthine–to judge acceleration and position change
  3. Proprioceptive–to judge posture
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2
Q

A positive Romberg test indicates what?

A

Somatosensory dysfunction (proprioception)

  • *With the eyes open, 3 sensory systems (vision, proprioception, and vestibular sense) provide input to the cerebellum to maintain balance
  • When pt closes eyes during Romberg test you remove that visual sense => thus, if problem, problem is [propioception] or [vestibular/labyrinth]
  • Romberg is NOT a test of cerebellar fx: these pts cannot stand with feet apart with eyes open OR closed
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3
Q

Realize the non-specific nature of the complaint of “poor balance”.

A

A sx, not a dx; means different think to different people; so you 1st have to define the symptoms and determine if it is central or peripheral

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4
Q

Illusion of movement of oneself or objects around self due to vestibular or neurologic dysfunction

A

Vertigo

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5
Q

Vertigo is often accompanied with what symptoms?

A

Sweating and nausea, sometimes associated with hearing impairment or tinnitus.

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6
Q

May be caused by vertigo but usually a nonvertiginous state of altered static or dynamic balance due to dysfunction of cerebellum, dorsal columns (sensory), motor systems (central or peripheral) or basal ganglia

A

Disequilibrium

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7
Q

Lightheadedness or impending LOC often due to orthostasis, arrhythmia, hyperventilation and aggravated by high temperature, prolonged standing, large meals

A

Presyncope

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8
Q

Vertigo is often due ot vestibular dysfunction of what structures?

A

Semicircular canal/otoliths

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9
Q

What are the main characteristics of sensory causes of Disequilibrium?

A
  1. Problem with propioception
  2. Visual impairment
  3. Compensated vestibular disorders
  4. Worse in dark
  5. Romberg sign
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10
Q

What are the main characteristics of motor causes of Disequilibrium?

A
  1. NO Romberg Sign
  2. Mechanical (arthritis)
  3. Peripheral or central (motor function).
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11
Q

What are the main characteristics of cerebellar causes of Disequilibrium?

A
  1. NO Romberg sign (cannot stand with feet together with eyes open or closed)
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12
Q

Peripheral/labyrinthine structures important to maintain equilibrium?

A
  • 1. Utricle
  • 2. Saccule
  • 3. Semicircular canals
  • 4. Vestibular nerve
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13
Q

Central structures important to maintain equilibrium?

A
  1. Cerebellum
  2. Vestibular nuclei
  3. Vestibulospinal
  4. Proprioceptive pathway
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14
Q

With Peripheral/labyrthine causes of dysequilibrium:

what is the vertigo like, duration of nystagmus, direction of nystagmus, and neuro symptoms?

A
  1. Intense vertigo
  2. Brief nystagmus
  3. FIXED horizontal/diagonal nystagmus (may be latent)
  4. NEVER neuro symptoms
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15
Q

With central dysfunction leading to dysequilibrium what is the vertigo like, duration of nystagmus, direction of nystagmus, and neuro symptoms?

A
  1. Mild vertigo
  2. Persistant nystagmus, which can be in vertical direction, but can change directions
  3. Usually some neuro symptoms
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16
Q

Is N/V more intense in central or peripheral causes?

A

Peripheral (intense)

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17
Q

Hearing loss is MC with ____ causes of dizziness.

A

Peripheral; rare in centrla

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18
Q

6 peripheral causes of vertigo

A
  1. Benign positional vertigo
  2. Vestibular neuronitis
  3. Meniere’s Disease
  4. Superior canal dehiscence
  5. Mal de Debarquement
  6. Drug induced ototoxicity
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19
Q

Most common cause of recurrent vertigo and characteristics?

A

- Benign Positional Vertigo: Brief recurrent episodes of vertigo triggered by changes in head positon

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20
Q
  1. What is Benign Positional Vertigo thought to be due to?
  2. How is this diagnosed?
  3. Direction of Nystagmus?
A
  1. Debris floating in endolymph of semicircular canal, MC posterior semicircular canal.
  2. Dix-Hallpike maneuver w/ affected ear down => causes TORSIONAL nystagmus
  3. Torsional
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21
Q

Dix-Hallpike maneuver should NOT be done in ________.

A

Spontaneous nystagmus, because you are trying to PROVOKE the nystagmus. Thus, only use for episodic.

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22
Q

BPV due to debris in horizontal semicircular canal

  1. Test:
  2. Nystagmus
A
  1. Supine Roll Test (Pagnini-McClure)
  2. Horizontal; changes direction
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23
Q

BPV due to debris in anterior semicircular canal

  1. Test:
  2. Nystagmus
A
  1. Dix Hallpike with the affected ear UP
  2. Downbeat and torsional
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24
Q

A patient with vertical positional nystagmus, such as seen in BPV with anterior semicircular canal affected requires what?

A

CAREFUL assessment to R/O brainstem or cerebellar lesions.

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25
Q

Treatment for Benign Postional Vertigo?

A
  1. Goes away on its own in a few weeks
  2. Positional exercises helpful: Sermont manuever
  3. Meds such as: vestibular suppressants, antiemetics, and anxiolytics
  4. PT: vestibular rehab/balance therapy
26
Q

How does Vestibular Neuronitis differ from BPV?

A
  • Spontaneous attack of vertigo, typically l_asting up to 2 weeks_ (findings similar to BPV) due to inflammation of CN 8; acute vertigo, N/V that peaks in 24 hours & NO hearing loss or tinnitus
  • But is NOT positonal
27
Q

What are the characteristics of Meniere’s Disease and who is most often affected?

Hallmarks?

A
  • Recurrent episodes of spontaneous vertigo, lasting >20min to hours, but less than 24 and dysequillibrium that can last several days.
    • Hallmark = Low frequency hearing loss
    • Tinnitus
    • Aural fullness “fullness in ear”
  • Woman are 3x more affected (20-50YO)
28
Q

What is Menieres Disease thought to be due to?

A

⬆︎ in the volume of endolymph in labyrinthe because of poor absorption (endolymphatic hydrops)

29
Q

Treatment for Meniere’s Disease?

A

Get rid of excess fluid (1 &2**)

  1. -* Sodium restriction
  2. -* Diuretics: thiazdies, furosemide
    • Sympmatic: lorazepam and diazepam
    • Sugery: endolymphatic sac decompression
30
Q

What are the characteristics of Mal de Debarquement (“Sickness of Disembarkment”)?

Duration?

Treatment?

A
    • Illusion of movement as an after effect of travel (sea, car, train)
    • Rocking, swaying feeling after getting off a boat almost immediately after the precipitating event (RARELY true vertigo)
    • Duration = usually <24 hours; sometimes longer
    • Tx: meclizine, scopolamine, benzodiazepines (dizziness meds)
31
Q

What are some of the drug induced causes of peripheral disequilibrium?

A
  1. Alcohol!
  2. Antibiotics - aminoglycosides, tetracycline, vancomycin
  3. Aspirin (salicylates)
  4. Diuretics
  5. -Chemotherapeutics: cisplatin, methotrexate, vincristine
32
Q

Disorders that are central causes of vertigo/dysequillibrium

A
  • 1. Vestibular migraine
  • 2. Infections
  • 3. Toxins/metabolic
  • 4. Cerebellopontine Angle Tumors
  • 5. Chiari malformation
  • 6. SCA (spinocerebellar ataxias)
33
Q

What are the requirements of diagnosis for a Vestibular Migraine (central)?

A
  1. At least 5 episodes of moderate/severe vestibular sx’s lasting 5min => 72 hours
  2. Current or previous hx of migraine w/ or w/o aura
  3. At least 50% of episodes have 1 or more migraine features: HA (unilateral, pulsatile), photophobia, phonophobia, nausea, aura…
34
Q

Central: Vascular (ischemic) causes of equilibrium disoders are most commonly seen in?

A

Elderly; abrupt onset with ischemia of labyrinth, brainstem or both.

35
Q

Repeated episodes of isolated vertigo without neurological symptoms should always suggest?

A

A non-neurologic cause

36
Q

What helps to distinguish brainstem lesion (esp. stroke) from peripheral lesion in a patient with an acute (not chronic) vestibular syndrome. More sensitive than MRI to detect acute stroke.

A

HINTS Test: Head Impulse-Nystagmus-Test of Skew

  1. Test nystagmus: spontaneous and gaze-evoked
  2. Test skew deviation: look for ocular misalignment (tell pt to look at docs nose and cover each eye; do many times)
  3. HIT (Head impulse test): move laterally 20 degrees and return rapidly back to midline everytime; switch
37
Q

When is a HINTS test abnormal => central cause/stroke?

A
  1. NL HIT test
  2. Nystagmus that is bidirectional or changes direction
  3. Presence of skew deviation
38
Q

HiNTs exam=> peripheral vertigo

A
  1. Positive/ABNL head impulse test,
  2. Unidirectional and horizontal nystagmus,
  3. Negative skew test
39
Q

What bacterial infections => central cause of dyequillibrium

A
  1. Meningococcal
  2. Pneumococcal
  3. H. flu
40
Q

If you see a vertical nystagmus, think of ______ as the cause.

A

CENTRAL = almost always pathomneumonic for brainstem dysfunction

  • Can also be BPV due to anterior semi-circular canal.
41
Q

How to perform Dix-Hallpike Maneuver for posterior- BPV?

A
    1. Have pt sit on bed.
    1. Turn patients head 45 degrees TOWARD L ear
    1. Lay patient down, with head hanging off bed and look at eyes.
      • = Torsional nystagmus (may not occur right away bc there is a latent period)
42
Q

What are metabolic and toxic (central) causes of dizziness?

A
  1. VitB12 deficieny
  2. Hypothyroidism
  3. Wilsons Disease
  4. Toxins: glue, ethanol (chronic alcohol affects cerebellar vermis)
43
Q
  1. What are Cerebellopontine Angle Tumors that are central causes of dizziness?
  2. What do they usually affect?
A
  1. Acoustic neuroma (Schwannoma)
  2. Meningioma
  3. Cholesteatoma

Usually affect CN 5, 7, 8.

44
Q

What is the first sign and the first symptom of a Cerebellopontine Angle Tumor?

A
  1. - First symptom = hearing loss (CN VIII)
  2. - First sign = absent corneal reflex (loss of CN V and VII)
45
Q

Paraneoplastic Cerebellar Degeneration is a central cause of dizziness: they can PRECEDE cancer diagnosis.

  1. Most commonly associated with what cancers?
  2. Antbodies cross react with?
A
  1. Breast, ovary and lung
  2. Ab to tumor cell antigens that attack Purkinje cells in the cerebellum.
46
Q

What are the most common forms of Spinocerebellar Ataxias?

Characteristic findings in these diseases?

A

- SCA 1 (olivopontocerebellar)

- SCA 3 (Machado-Joseph)

*Slowly, progressive cerebellar ataxia of limbs + brainstem signs (dysarthria, oculomotor disturbance, spasticity) + peripheral neuropathy. Affect gait early => bed confinment => all => death

47
Q

When is the typical onset of Friedrich’s Ataxia and what are the common findings?

A
  • AR disorder due to mutation on Chr9 that appears before 20 YO (young persons disease)
  1. - Gait ataxia w/ absent tendon relfexes in legs and muscle weakness
    • Extensor plantar responses
    • Pes cavus
    • Kyphoscoliosis
48
Q

Common cause of death in someone with Friedrich’s Ataxia?

A

Cardiomyopathy: death by 35 YO

49
Q

What is the age of onset for LOFA (Late-onset Friedrichs Ataxia)?

A

After 25 YO: less dramatic course

50
Q

Age of onset for Ataxia-Telangiectasia?

Common findings?

A
  • Disease of infancy (<4 yr. of age)
  • Progressive pancerebellar degeneration involving nystagmus, dysarthria, and [gait, limb and trunk ataxia], oculoculocutaneous telangiectasia** (port-wine stain from forehead => eye) and immunodeficiency**.
  • Choreoathetosis, loss of vibration and position sense in legs, areflexia, and disorders of voluntary eye movements
51
Q

What age does Oculocutaneous telangiectasia usually appear?

Common findings?

A
    • Usually appears in teens
  • - Immunological impairment (⬇︎ IgA and IgE) usually evident later on => causing recurrent sinopulmonary infections
    • Changes of skin and hair, hypogonadism, and insulin resistance
52
Q
  • Where is Spondylosis (degenerative changes of spine) most commonly seen?
  • Can lead to?
  • Early signs?
A
  • Cervical region
  • Can lead to myelopathy (spondylotic), compress SC and/or nerve roots
  • Unexplained gait impairment or imbalance often an early symptom in OLDER PPL
53
Q

What will examination of someone with Spondylotic Myelopathy show?

A
  1. MCC of myelopath in elderly (>55 YO)
  2. Spastic tone in legs
  3. ⬆︎ knee/ankle jerks
  4. Babinski signs
  5. Variable sensory deficits
54
Q

What can cause B12 deficiency?

A
  1. Malabsorption syndromes (bc binds to intrinsic factor in duodenum and absorbed in ileum)
  2. Surgery (gastric bypass, ileectomy)
  3. Drugs (H2 receptor antagonists)
  4. Nitrous oxide (whip-its!!!)
  5. Fish tapeworm

Can all lead to => degeneration of posterior colum and lateral corticospinal tract (combined systems degeneration); + peripheral neuropathy and dementia

55
Q

What does VitB12 do?

A
    1. Homocysteine => methionine
    1. Methymelonic acid => SucCoA
56
Q

Clinical fx of Vit B12 deficiency

A
  1. Insidious onset
  2. V tired
  3. + Rhomberg and Babinksi
  4. Gait and balance problems
57
Q

Diagnosis of VitB12 deficiency

A
  1. +/- anemia
  2. +/- hypersegmented polys
  3. ↓ serum B12
  4. ↑ homocysteine and methylmalonic acid
  5. Presence of clinical syndrome
58
Q

What type of syndrome can be caused by Vitamine E deficiency?

A

Spinocerebellar similiar to Friedrich’s

59
Q

The syndrome associated with Copper deficiency (DECREASED urine Cu and DECREASE serum ceruloplasmin) can present very similar to what?

A

B12 deficiency

60
Q

How is diagnosis of Nitrous Oxide Toxicity made and what is the treatment?

A
  • Diagnosis: HX and ⬇︎ of Vit B12 w/ similar symptoms
  • Tx: B12 replacement

NMSK Exam 2: Neuro (15 decks)

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