Dizziness Flashcards
Mrs. Jones is a 67 year old woman with a PMH of smoking and HTN. She takes lisinopril 10mg daily. She presents to her primary physician complaining of dizziness. What is the first thing we need to do with this pt?
Have her define the dizziness.. what do you mean by dizzy?
Key to differentiate between vertigo from presyncope
define true vertigo
True vertigo should have an aspect of movement – spinning of self or room
Common shit people describe as dizziness
- Presyncope
- Unsteadiness of gait (peripheral neuropathy)
- Blurry or double vision
- Cloudy mentation - disorientation
- Migraine aura
- Seizure aura
- Anxiety
You determine your pt has vertigo, what associated symptoms do you look for?
- Cranial nerves
- Hearing
- Ataxia
• Cardiovascular
What is the difference between peripheral and central vertigo
Peripheral vertigo tends to have a delay after stimulation (a second or two) and does exhibit fatigue
C_entral vertigo_ has no delay and is usually much more profound and prolonged with little fatigue
• Imbalance in input from either inner ears, vestibular nuclei or vestibular tracts
- Sensation of movement without any
- Misperception of movements one is making
More ways to define vertigo
What do the following have in common?
BPPV
Meniere’s
Vestibular Neuronitis
Labyrinthitis
Direct trauma
All Peripheral causes of Vertigo
What do the following have in common?
Stroke – lateral medullary, cerebellum
Brainstem or cerebellar mass Medications
Migraine
MS
Anxiety
All central causes of vertigo
What part of the ear detects linear movment?
The maculae in the utricle and sacculae:
when otoconia and endolymph move over hair cells sends signal
Semicircular canals detect______ motion, each in its own plane.
angular
What are the labels in the image
• 1 = Lateral Semicircular Canal
- 2 = Vestibule
- 3 = Internal Auditory Canal
What are the labeled images
- Posterior Semicircular Canal
- Mastoids
Where are the superior and lateral vestibular nucleus located?
caudal pons
Where are the Medial and Inverior vesibular nucleus located?
Rostral Medulla
Pathway and function of Medial Vestibulospinal tract
helps balance in neck and axial muscles
Pathway and function of lateral vestibulospinal tract
Balance for ipsilateral proximal muscles
She describes two days of having a severe sensation of spinning when she sits up or rolls over, lies down or even when she turns to the left. She has to sit down or hold on and close her eyes to keep from falling or throwing up. It goes away after about 30 seconds. She does not have any hearing changes or other neurologic symptoms.
BPPV
You suspect your patient has BPPV based on her history, what is the next step?
Do a complete exam
• Look for nystagmus
Look for associated symptoms: ataxia, dyshpagia, diplopia, facial sensation loss, weakness, numbness, ect.
What types of nystagums are central?
Vertical and direction changing:
if there is no nystagmus, it’s NOT ear related
If patient has vertigo as well as ataxia, what would you want to include on Ddx?
Cerebellar lesion
What type of symptoms are suggestive of a brainstem stroke?
Dysphagia, diplopia, facial sensation loss, horners, skew deviation
What special test do we do to dx Bppv?
Dix-Hallpike maneuvar
How do you perform a Dix-Hallpike maneuver and what do you expect to see?
Drop the patient backwards and then turn the head sideways and down towards the floor
- Ask the patient to look toward the floor and watch for nystagmus
- In peripheral nystagmus you will see it develop after a few seconds and last for under a minute
Pt has Peripheral vertigo with Long duration dizziness and hearing loss
Labryinthitis
Pt has peripheral vertigo with Short duration dizziness and Hearing loss
Meniere’s Disease
Pt has peripheral vertigo with intact hearing and Long duration dizziness
Vestibular Neuritis
Pt has peripheral vertigo, intact hearing and short duration dizziness
BPPV
What causes BPPV and what is a way to tx it?
cause by misplaced otolinth, can treat with the Epley maneuvar to try and get otolith back into utricle
What would you want to look into if your patient informs you they feel dizzy when they are sitting for a time then stand up?
Suggestive of orthostatic hypotension: usually more lightheaded then vertigo:
check pts Medication, if they are Hyponatremic or dehydrated, have autonomic failure
How do you test orthostasis correctly?
Start supine, then sitting, then standing with >3 minutes in each position prior to testing
• >20mmHG drop in SBP or >10mmHg drop in DBP after 3 minutes is diagnostic
Tilt table testing for autonomic insufficiency
True vertigo (not lightheadedness) with standing up for a period of time
• Consider :
vertebrobasilar insufficiency
What can cause vertebrobasilar insufficiency?
Stenosed or occluded vertebral arteries BILATERALLY or stenosed or occluded basilar
artery
Ischemia of vestibular nuclei in the pons and medulla can present with vertigo Often with other associated symptoms such as weakness, diplopia, dysarthria
He describes the sensation of falling to the left which particularly occurs when he is walking. He often bumps into things when he walks. He feels like he is walking on a boat sometimes and sometimes feels himself swaying when he stands still. He has been dropping things in his left hand as well. He denies hearing changes and is not aware of any other neurologic symptoms.
DDx
Cerebellar ataxia, cerebellar stroke, alcoholism
Left side cerebellar lesion
Prion disease, MS, truama
Your pt comes in with symptoms of a cerebellar lesion, you are thinking this may be due to a stroke. What imaging would you want done and why?
CT: quick and cheap and better for screening
or
MRI: masses, ischemia, and MS changes (go with this one)
What is the differential dx for a solid enhansing mass in the posterior fossa?
May be glioblastoma, schwannoma, meningioma
Mass is seen on MRI described as solid, enhancing and has a tail on it. Dx?
Meningioma: will have dural tails on them
often slow growing and benign
What tumors are more commonly seen in children in the brainstem or cerebellum
- Medulloblastoma
- PNET
- Pineal tumors
- Ependymoma
- Astrocytomas of BS and cerebellum (25% of kids tumors)
• Gliomas – almost exclusively children/young adults
Metastases to the brain are more common in
adults
What type of brain tumors cause extra-axial cerebellar compression?
Extra-axial cerebellar compression from meningioma, acoustic neuroma
What are the signs and symptoms of a Lateral Medullary syndrome
dysphagia, Horner’s syndrome, ataxia, sensory loss, nystagmus, vertigo
What age population is lateral medullary syndrome common in and what is the cause?
Seen in young people; often from vertebral artery dissection
What do we see on MRI of ind with MS?
See plaques throughout CNS; show up bright white
What type of meds cause Lightheadedness/presyncope
- BP meds
- Psych meds
- Neuro meds
What two drugs cause true vertigo
Phenytoin and ethenol lead to cerebellar degeneration
What drugs will cause vestibulotoxicity?
- Aminoglycosides–gentamicin,tobramycin
- Chemotherapy–Cisplatin,vincristine
