Neuro Flashcards
What is BPPV?
Benign paroxysmal positional vertigo (BPPV) is a common cause of recurrent episodes of vertigo triggered by head movement. It is a peripheral cause of vertigo, meaning the problem is located in the inner ear rather than the brain. It is more common in older adults.
Presentation of BPPV?
A variety of head movements can trigger attacks of vertigo. A common trigger is turning over in bed. Symptoms settle after around 20 – 60 seconds, and patients are asymptomatic between attacks. Often episodes occur over several weeks and then resolve but can reoccur weeks or months later.
Does BPPV cause hearing loss or tinnitus?
No
Pathophysiology of BPPV?
BPPV is caused by crystals of calcium carbonate called otoconia that become displaced into the semicircular canals. This occurs most often in the posterior semicircular canal. They may be displaced by a viral infection, head trauma, ageing or without a clear cause.
The crystals disrupt the normal flow of endolymph through the canals, confusing the vestibular system. Head movement creates the flow of endolymph in the canals, triggering episodes of vertigo.
How is BPPV diagnosed?
The Dix-Hallpike manoeuvre can be used to diagnose BPPV (Dix for Dx – diagnosis).
What is the Dix-Hallpike Manoeuvre?
It involves moving the patient’s head in a way that moves endolymph through the semicircular canals and triggers vertigo in patients with BPPV. Check the patient can do the manoeuvre safely before performing it, for example, ensuring they have no neck pain or pathology.
To perform the manoeuvre:
The patient sits upright on a flat examination couch with their head turned 45 degrees to one side (turned to the right to test the right ear and left to test the left ear)
Support the patient’s head to stay in the 45 degree position while rapidly lowering the patient backwards until their head is hanging off the end of the couch, extended 20-30 degrees
Hold the patient’s head still, turned 45 degrees to one side and extended 20-30 degrees below the level of the couch
Watch the eyes closely for 30-60 seconds, looking for nystagmus
Repeat the test with the head turned 45 degrees in the other direction
What does the Dix-Hallpike Manoeuvre show for people with BPPV?
In patients with BPPV, the Dix-Hallpike manoeuvre will trigger rotational nystagmus and symptoms of vertigo. The eye will have rotational beats of nystagmus towards the affected ear (clockwise with left ear and anti-clockwise for right ear BPPV).
How do you treate BPPV?
The Epley manoeuvre can be used to treat BPPV. The idea is to move the crystals in the semicircular canal into a position that does not disrupt endolymph flow.
How do you perform the Epley manoeurve?
Follow the steps of the Dix-Hallpike manoeuvre, having the patient go from an upright position with their head rotated 45 degrees (to the affected side) down to a lying position with their head extended off the end of the bed, still rotated 45 degrees
Rotate the patient’s head 90 degrees past the central position
Have the patient roll onto their side so their head rotates a further 90 degrees in the same direction
Have the patient sit up sideways with the legs off the side of the couch
Position the head in the central position with the neck flexed 45 degrees, with the chin towards the chest
At each stage, support the patient’s head in place for 30 seconds and wait for any nystagmus or dizziness to settle
What can be done to improve the symptoms of BPPV?
Brandt-Daroff exercises can be performed by the patient at home to improve the symptoms of BPPV. These involve sitting on the end of a bed and lying sideways, from one side to the other, while rotating the head slightly to face the ceiling. The exercises are repeated several times a day until symptoms improve.
Causes of BPPV
Most cases of BPPV are idiopathic.
Other known causes of BPPV include:
Head injury
Vestibular neuronitis (post-viral illness)
Labyrinthitis (due to age-related degeneration of the labyrinth)
Complications of mastoid/stapes surgery
Risk factors of BPPV
Older age (onset common between 40 to 60 years old).
Female sex (women are twice as likely to have BPPV compared to men)
Meniere’s disease (usually diagnosed alongside BPPV in 30% of cases)
Patients with migraines and/or anxiety disorders
Differential Dx for BPPV
Persistent vertigo: indicative of Meniere’s disease
Tinnitus, hearing loss or aural fullness: indicative of Meniere’s disease, labyrinthitis
Long and gradual onset, viral prodrome: indicative of vestibular neuronitis, labyrinthitis
Visual, speech, motor or sensory loss: indicative of a CNS lesion
Vertical/down-beating nystagmus: indicative of a CNS lesion
Recurrance rate for BPPV
Around half of people with BPPV will have a recurrence of symptoms 3-5 years after their diagnosis
What is cognitive impairment?
Cognitive impairment is a decline in mental functions such as memory, attention, language, or problem-solving, which may range from mild to severe.
What are the categories of cognitive impairment?
Mild Cognitive Impairment (MCI) – noticeable decline not affecting daily function.
Dementia – significant impairment that interferes with independence.
Delirium – acute, fluctuating cognitive dysfunction.
What are the common causes (aetiologies) of cognitive impairment?
Neurodegenerative diseases (e.g., Alzheimer’s, Parkinson’s, Lewy body dementia).
Vascular causes (e.g., multi-infarct dementia).
Metabolic or systemic (e.g., hypothyroidism, B12 deficiency).
Psychiatric disorders (e.g., depression).
Drugs and alcohol misuse.
Delirium (acute, often reversible).
What are typical symptoms of mild cognitive impairment (MCI)?
Subtle memory loss, difficulty concentrating, and slower thought processing, with preserved ability to perform daily activities.
What are the hallmark features of dementia?
Memory loss.
Language difficulties.
Impaired reasoning/judgment.
Personality changes.
Disorientation in time or place.
What red flags suggest a diagnosis of delirium rather than dementia?
Acute onset, fluctuating consciousness, impaired attention, and hallucinations.
What screening tools are used for assessing cognitive function in the UK?
GP COG
Mini-Mental State Examination (MMSE)
Montreal Cognitive Assessment (MoCA)
Addenbrooke’s Cognitive Examination (ACE-III)
A MMSE score <__________ suggests significant cognitive impairment.
24
What blood tests should be ordered in a patient with suspected cognitive impairment?
FBC, U&Es, LFTs
Thyroid function tests
Vitamin B12 and folate
Glucose
Calcium
CRP/ESR (if infection suspected)
What imaging may be considered in cognitive impairment?
CT head (non-contrast): to rule out structural pathology.
MRI brain: more sensitive for vascular and atrophic changes.
What are non-pharmacological interventions for cognitive impairment?
Cognitive stimulation therapy (CST)
Lifestyle changes (exercise, diet, social engagement)
Carer support and education
Advanced care planning
What pharmacological treatments are used in Alzheimer’s disease?
Acetylcholinesterase inhibitors (donepezil, rivastigmine, galantamine)
NMDA receptor antagonist (memantine in moderate-severe cases)
Donepezil is a __________ used in mild to moderate Alzheimer’s disease.
cholinesterase inhibitor
When should cognitive enhancers be stopped?
If the patient develops intolerable side effects or there is no observed benefit after a period of treatment.
What are the potential complications of untreated cognitive impairment?
Functional decline and loss of independence
Malnutrition and dehydration
Falls and injuries
Social isolation and carer burden
Institutionalisation
Behavioural and psychological symptoms (e.g., aggression, depression)
