Dizziness

Question 1

causes (w/%) of dizziness

Answer 1

33% - vestibular
20% - cardiovascular
10-15% - psychogenic
10% - idiopathic
5% - stroke in posterior circulation (brainstem or cerebellum)

Question 2

vestibular causes of dizziness

Answer 2

BPPV (benign paroxysmal positional vertigo), viral labyrinth infection, vestibular migraine, Meniere’s disease, acoustic neuroma, bilateral vestibulopathy due to ototoxic drugs

Question 3

3 types of dizzines

Answer 3

vertigo (vestibular), presyncope (cardiovascular), imbalance (cerebellar)

Question 4

blood supply to brainstem, cerebellum, and vestibular organs (inner ear)

Answer 4

posterior circulation - mainly vertebral, basilar, PICA; less so AICA, SCA

Question 5

dx for 1st episode of acute onset of dizziness lasting > 24 h

Answer 5

acute vestibular syndrome

Question 6

causes of acute vestibular syndrome

Answer 6

1. viral vestibular neuritis - peripheral

2. stroke in posterior circulation - central (25%)

Question 7

central vs peripheral vestibulopathy - onset

Answer 7

central - acute (seconds to minutes)

peripheral - subacute (hours)

Question 8

central vs peripheral vestibulopathy - balance impairment

Answer 8

central - severe, out of proportion with dizziness (if present)
peripheral - mild to moderate

Question 9

central vs peripheral vestibulopathy - presence of n/v

Answer 9

central - out of proportion with dizziness (if present)

peripheral - may occur

Question 10

central vs peripheral vestibulopathy - craniocervical pain

Answer 10

central - 40% (in 75% of dissection)

peripheral - 10%

Question 11

central vs peripheral vestibulopathy - likelihood of stroke risk factors being present

Answer 11

central - more likely

peripheral - less likely

Question 12

central vs peripheral vestibulopathy - > 50 yo

Answer 12

central - more likely

peripheral - less likely

Question 13

central vs peripheral vestibulopathy - nystagmus

Answer 13

central - central type

peripheral - peripheral type

Question 14

central vs peripheral vestibulopathy - neuro signs and symptoms

Answer 14

central - can be present

peripheral - absent

Question 15

cause of peripheral nystagmus

Answer 15

labyrinth dysfunction

Question 16

characteristics of peripheral nystagmus (direction, duration, more/less prominent, patient appearance)

Answer 16

• horizontal, mainly (small torsional component)
• beats away from lesion, similar to cold (COWS)
• beats unidirectionally
• transient (one to few days)
• more prominent w/gaze in direction of beat, and during funduscopic exam
• less prominent in light/fixation
• sick looking patient

Question 17

types of central nystagmus

Answer 17

• gaze evoked (most common)
• upbeat
• downbeat
• pure torsional (rare)

Question 18

any age
dizziness that worsens over minutes to hours
some nausea, sense of imbalance, blurry vision
appears ill
peripheral nystagmus
no neuro findings

Answer 18

viral peripheral vestibulopathy

Question 19

typically female in 30s/40s
hx of migraines in teens/20s
hx of motion sickness as child

Answer 19

vestibular migraine

tx: migraine meds
very common, ~1/4 migraine sufferers

Question 20

older patient
recurrent dizzy spells
last

Answer 20

BPPV (benign paroxysmal positional vertigo)

• loosening of otoliths (most commonly lodge in posterior canal)
• tx: PT
• torsional nystagmus seen on Dix-Hallpike maneuver only

Question 21

variable age of onset, usually 30-60
recurrent dizzy spells
last minutes to hours
associated with fluctuant hearing loss

Answer 21

Meniere disease

*refer to ENT

Question 22

stroke in dorsolateral medulla

Answer 22

dizziness
sensory loss
ataxia
hiccups

Question 23

PICA stroke (limited to inferior cerebellum)

Answer 23

dizziness
horizontal nystagmus

can mimic peripheral cause

Question 24

AICA stroke

Answer 24

rarely presents with isolated dizziness, due to infarction of the labyrinth

can mimic peripheral cause

Question 25

SCA stroke

Answer 25

imbalance
dysarthria
less prominent dizziness