Vertigo Flashcards
Vertigo
Sensation of the room spinning
Presentation of vertigo
Dizziness
Associated with:
- Nausea and vomiting
- Sweating
- Feeling generally unwell
Sensory inputs for balance
Vision
Proprioception
Signals from the vestibular system
Pathophysiology of vertigo
Mismatch between the sensory inputs of balance
Rombergs test
Closing your eyes whilst standing to see if you can balance
Vestibular nerve
Vestibular nerve carries signals from the vestibular apparatus to the vestibular nucleus in the brainstem and the cerebellum
Classification of vertigo
- Peripheral problem - affecting the vestibular system
- Central problem - involving the brainstem or the cerebellum
Common causes of peripheral vertigo
Benign paroxysmal positional vertigo
Ménière’s disease
Vestibular neuronitis
Labyrinthitis
Other causes of peripheral vertigo
Trauma to the vestibular nerve
Vestibular nerve tumours (acoustic neuromas)
Otosclerosis
Hyperviscosity syndromes
Ramsay Hunt syndrome
Causes of central vertigo
Posterior circulation infarction (stroke)
Tumour
Multiple sclerosis
Vestibular migraine
Features of central vertigo
Sustained, non positional vertigo
Posterior circulation infarction presentation
Sudden onset
Associated with other symptoms, such as ataxia, diplopia, cranial nerve defects or limb symptoms
Tumour presentation
Gradual onset with associated symptoms of cerebellar or brainstem dysfunction
Multiple sclerosis
Relapsing and remitting symptoms, with other associated features of multiple sclerosis, such as optic neuritis or transverse myelitis
History of vertigo
Onset Duration Hearing loss or tinnitus Coordination Nausea
Examination for vertigo
Ear examination -signs of infection or other pathology
Neurological examination -central causes of vertigo (e.g., stroke or multiple sclerosis)
CVS exam - CVS causes of dizziness (e.g., arrhythmias or valve disease)
Special tests
Special tests for vertigo
Romberg’s test - problems with proprioception or vestibular function
Dix-Hallpike manoeuvre - to diagnose BPPV
HINTS examination - to distinguish between central and peripheral vertigo
HINTS examination
HI – Head Impulse
N – Nystagmus
TS – Test of Skew
Head Impulse Test
- Patient sitting upright and fixing their gaze on the examiner’s nose
- The examiner holds the patient’s head and rapidly jerks it 10-20 degrees in one direction while the patient continues looking at the examiner’s nose.
- The head is moved slowly back to the centre before repeating in the opposite direction.
- Ensure they have no neck pain or pathology before performing the test.
Abnormal head impulse test
Abnormally functioning vestibular system - the eyes will saccade (rapidly move back and forth) as they eventually fix back on the examiner
Peripheral cause of vertigo - may be positive
Central cause - normal
Test of Skew
- Patient sitting upright and fixing their gaze on the examiner’s nose.
- The examiner covers one eye at a time, alternating between covering either eye.
- The eyes should remain fixed on the examiner’s nose with no deviation.
Abnormal test of skew
Vertical correction when an eye is uncovered (the eye has drifted up or down and needs to move vertically to fix on the nose when uncovered) - indicates a central cause of vertigo
Management of peripheral vertigo
Peripheral vertigo:
- Prochlorperazine
- Antihistamines promethazine
- Betahistine - Meniere’s disease
Avoid triggers and triptans - vestibular migraine
DVLA advice for vertigo
Patients must not drive and must inform the DVLA if they are liable to “sudden and unprovoked or unprecipitated episodes of disabling dizziness”
Management of central vertigo
Referral for CT/ MRI head to establish cause
