Neurology 15 - A Scientific & Clinical Approach to Vertigo

Question 1

Define dizziness

Answer 1

An illusion of self and/or environmental motion

Question 2

Define vertigo

Answer 2

• Illusory selfmotion which is spinning in nature

- A form of dizziness

Question 3

Define oscillopsia

Answer 3

Visual world motion

Question 4

Recognise how oscillopsia differs from vertigo

Answer 4

Vertigo is present even when the eyes are shut

Question 5

How is vertigo diagnosed?

Answer 5

• Combining anatomy, physiology, symptoms and signs

Question 6

Describe the anatomy of vertigo

Answer 6

• Inner ear detects head movement
• Semicircular canals detects angular accelleration
• Otolith organs act as an accellerometer
• Cerebral cortex
• Subcortical - cerebellum, vestibular nuclei or cerebral cortex
• Temporal and parietal cortex

Question 7

List the causes of acute vertigo and describe their frequency

Answer 7

• BPPV - 35%
• Vestibular Neuritis - 15%
• Migrainous vertigo - 15%
• Stroke - 5%
• Mixed (syncope, anxiety) - 30%
• Menieres (<1%)

Question 8

List the core examinations in vertigo

Answer 8

• Eyes show nystagmus, head impulse test and Hallpike test are used, fundoscopy, cover and gaze
• Ears - use otoscopy
• Legs - gait ataxia

Question 9

List the red flags for BPPV

Answer 9

• Headache

- Atypical nystagmus (downwards, central cause)

Question 10

List the treatments available for BPPV

Answer 10

• Epley

- Right hallpike and semont manouvre

Question 11

What is vestibular-motion perception?

Answer 11

Sensation of movement (movement of self or of envirnoment)

Question 12

What is seeing environmental motion?

Answer 12

Oscillopsia (indicates a nystagmus)

Question 13

What is looked at first in acute vertigo?

Answer 13

• Postural blood pressure (presyncope)
• Atertial saturation (pulmonary embolism)
• ECG (cardiac dysrhythmia)

Question 14

What is the head impulse test?

Answer 14

• Vestibulooccular reflex not working
• Ask the patient to fix their eyes and move their head
• Eyes will remain in the same position then move to the correct position after a few seconds, rather than immediately

Question 15

How are the legs assessed in acute vertigo?

Answer 15

• Gait (narrow based)
• Tandem walking (count how many mistakes out of 10 tandem steps - walking on straight line)
• Romberg (see if eye closure affects balance, can they maintain balance for over 20 seconds without vision)

Question 16

What is BPPV?

Answer 16

• The sudden sensation that you’re spinning or that the inside of your head is spinning.
• Causes brief episodes of mild to intense dizziness
• Loose chalk crystals get into the wrong part of the inner ear

Question 17

What is vestibular agnostia?

Answer 17

Patients loose sensation of vertigo

Question 18

What is vestibular neuritis?

Answer 18

• Subacute onset (minutes-hours)
• Continuous vertigo
• Obvious vestibular nystagmus
• Positive head impulse test
• Normal gait
• Peripheral

Question 19

What is the treatment of vestibular neuritis?

Answer 19

• Vestibular sedatives for 24-36 hours
• Mobilise at day 2 or 3
• Treat any BPPV or migraine

Question 20

List the red flags for vestibular neuritis

Answer 20

• Headache (40% posterior circulation stroke)
• Gait ataxia
• Hyperacute onset (vascular onset)
• Vertigo and hearing loss
• Prolonged symptoms (over 4 days suggest floor of 4th ventricle problem)

Question 21

What is acute vestibular migraine?

Answer 21

• History of migraine
• Acute vertigo without prominant headache
• Recurrent
• Diagnosis of exclusion

Question 22

List the red flags for acute vestibular migraine

Answer 22

• Headache
• Gait problems
• Hyperacute onset
• Hearing loss
• Prolonged symptoms

Question 23

What is the result of cerebellar stroke?

Answer 23

• Thunderclap onset vertigo (embolic - valsalva or atrial dibrillation? Dissection - neck pain - stretching or trauma?)
• Poor balance (unable to walk or even sit)
• Headache

Question 24

List the red flags of cerebellar stroke?

Answer 24

• Headache
• Gait problems
• Hyperacute onset
• Hearing loss
• Prolonged symptoms