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Adv Neuro: Vestibular > Week 1 Highlights > Flashcards

Week 1 Highlights Flashcards

Oculomotor/Vestib Exam, BPPV, & other resources

1
Q

peripheral vs central nystagmus

pattern of mvmt

A

peripheral: horizontal
* mixed plane (torsional w/ horizontal or vertical component)

central: vertical or torsional
* single plane

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2
Q

peripheral vs central nystagmus

consistency of pattern

A

peripheral - doesn’t change

central - direction and pattern may change

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3
Q

peripheral vs central nystagmus

effect of gaze

A

peripheral
* fast phase always to same side
* inc w gaze toward direction of fast phase

central
* no change or fast phase reverses direction

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4
Q

peripheral vs central nystagmus

fatigability

A

peripheral - fatigues, adaptation

central - doesn’t fatigue

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5
Q

peripheral vs central nystagmus

duration

A

peripheral - varies depending on dx but usually short duration

central - can be longer duration or >1min

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6
Q

peripheral vs central nystagmus

unilateral vs bilateral

A

peripheral - always bilateral

central - can be unilateral or bilateral

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7
Q

peripheral vs central nystagmus

effect of fixation

A

peripheral - dec amplitude

central - no impact or inc amplitude

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8
Q

peripheral vs central nystagmus

onset tempo

A

peripheral - often sudden (minutes)

central - often more gradual (more than an hour)

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9
Q

peripheral vs central nystagmus

severity

A

peripheral - mod to severe

central - mild to mod

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9
Q

peripheral vs central nystagmus

symptom pattern

A

peripheral - intermittent
* tends to be more peripheral in nature

central - persistent sx
* either peripheral or central

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10
Q

peripheral vs central nystagmus

headache

A

peripheral - usually absent

central - often present

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11
Q

peripheral vs central nystagmus

course throughout the day

A

peripheral - worse in AM, improves as day proceeds

central - no impact

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12
Q

peripheral vs central nystagmus

positional

A

peripheral - often, depends on etiology

central - minimal impact
* presence of positional impact doesn’t r/o central etiology

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13
Q

peripheral vs central nystagmus

concomitant ear sx

A

peripheral - dec hearing or tinnitis = peripheral cause more likely

central - rare, U/L sudden onset
* could be seen in TIA, interanl auditory artery or AICA stroke

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14
Q

peripheral vs central nystagmus

concomitant neurologic sx

A

peripheral - any neuro complaint = peripheral less likely

central - any neuro complaint = central more likely
* esp diplopia, dysarthria, true ataxia

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15
Q

peripheral vs central nystagmus

gait instability

A

peripheral - tendency to fall to one side

central - tendency to fall to either side

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16
Q

peripheral vs central nystagmus

imbalance

A

peripheral - mild to mod

central - severe

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17
Q

peripheral vs central nystagmus

n/v

A

peripheral - severe

central - variable, may be minimal

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18
Q

acute vestibular syndrome

what is it
5 differential dx

A

acute persistent continuous dizziness lasting days to weeks and usually associated w n/v and intolerance to head motion

  1. vestib neuritis
  2. labyrinthitis
  3. post circulation stroke
  4. demyelinating dz
  5. post-traumatic vertigo
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19
Q

triggered episodic vestib syndrome

what is it
6 differential dx

A

episodic dizziness triggered by specific and obligate actions, usually a change in head or body position; episodes generally last <1min

  1. BPPV
  2. postural HTN
  3. perilymph fistula
  4. superior canal dehiscence syndrome
  5. vertebrobasilar insufficiency
  6. central paroxysmal positional vertigo
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20
Q

spontaneous episodic vestib syndrome

what is it
5 differential dx

A

episodic dizziness not triggered and can last minutes to hours

  1. vestib migraine
  2. meniere’s dz
  3. post circulation TIA
  4. med side effects
  5. anxiety or panic disorder
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21
Q

peripheral vs central nystagmus

symptom pattern

A

peripheral - intermittent
* tends to be more peripheral in nature

central - persistent sx
* either peripheral or central

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21
Q

chronic vestib syndrome

what is it
5 differential dx

A

dizziness lasting weeks to months or longer

  1. anxiety or panic disorder
  2. med side effects
  3. post-traumatic vertigo
  4. post fossa mass lesions
  5. cervicogenic vertigo (variable)
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22
Q

what does alexander’s law mean

A

when gaze is shifted in direction of fast phase, nystagmus will become more pronounced

when gaze is shifted in direction of slow phase, nystagmus will diminish

23
Q

what are the 3 degrees of nystagmus according to alexander’s law

A

1st: nystagmus on intact side only
2nd: nystagmus to intact side and in central position
3rd: nystagmus in all 3 directions

24
Q

when do you usually see 3rd degree nystagmus (per alexander’s law)

A

acute stages w/ vestib neuritis and labyrinthitis

25
Q

what is optokinetic nystagmus (OKN)

A

normal eye mvmt elicited by tracking of moving field

26
Q

how does OKN present with distinct moving targets

A

OKN generally contains within it a smooth pursuit

27
Q

what is the function of OKN

A

allows you to follow objects in motion while head remains stationary

28
Q

how is OKN different from smooth pursuit

A

smooth pursuit - eye mvmt elicited by tracking a single distinct target

OKN - tracking a moving field

29
Q

chronic vestib syndrome

what is it
5 differential dx

A

dizziness lasting weeks to months or longer

  1. anxiety or panic disorder
  2. med side effects
  3. post-traumatic vertigo
  4. post fossa mass lesions
  5. cervicogenic vertigo (variable)
29
Q

peripheral vs central nystagmus

symptom pattern

A

peripheral - intermittent
* tends to be more peripheral in nature

central - persistent sx
* either peripheral or central

29
Q

what is the ocular tilt reaction (OTR)

A

triad comprising head tilt, conjugate ocular torsion, and hypotropia d/t skew deviation

30
Q

how will a (+) OTR present

A

head tilt toward side of lower eye and ocular torsion in same direction w upper poles of eye rotating to lower eye

31
Q

how will (+) OTR present in cerebellar lesions

A

ipsi or contra depending on structures involved

32
Q

describe the course of the pathway responsible for OTR and how the location of the lesion will impact the (+) OTR presentation

A

crosses the midline above the abducens nucleus level and ascend into contralateral MLF

  1. below lower pons = ipsi
  2. more rostral = contra
33
Q

how do you determine the side of the lesion in contraversive vs ipsiversive abnormal OTR

A

the lesion is ipsi or contralateral to the lowermost eye

34
Q

what is the pathological ocular tilt reaction (OTR)

A

triad comprising head tilt, conjugate ocular torsion, and hypotropia d/t skew deviation

35
Q

how will peripheral lesions impact all parts of the OTR

peripheral - utricle, vestib n., medial and superior vestib nuclei

A

all tilt effects (perceptual, ocular motor, postural) are all ipsiversive

ipsiversive = lesion is ipsilateral to the lowermost eye

36
Q

what are examples of potential etiologies of eye mvmt abnormalities on pressure change

A
  • abnormalities at craniocervical junction (ie arnold-chiari malformation)
  • disorders of inner ear - ie perilymphatic fistula, superior canal dehiscence (SCD)
  • middle ear problems with ossicular chain
37
Q

what are 3 examples of pressure tests to use to sus out any eye mvmt abnormalities on a pressure change

A
  1. tragal compression
  2. valsalva
  3. hyperventilation (1 breath/sec x40-60)
38
Q

what is the key to dx a SCD etiology for an eye mvmt abnormality w pressure changes

A

thorough hx
subjective c/o
* sensitive to noise
* can hear heartbeat
* can hear eyeballs move

39
Q

what is the most commonly involved SCC in BPPV

A

posterior

40
Q

BPPV

post SCC nystagmus presentation

A

upbeating and torsional

41
Q

BPPV

ant SCC nystagmus presentation

A
  • downbeating and torsional
  • or just downbeating
42
Q

BPPV

lat SCC nystagmus presentation

A

horizontal nystagmus (geo vs apogeo)

43
Q

BPPV lateral SCC nystagmus

geotropic vs apogeotropic

A

geotropic -> ground loving
* side of inc intensity = side of affected LC = canalithiasis

  • apogeotropic -> away from ground, to ceiling
  • side of lesser intensity = side of affected LC = cupulolithiasis

in lateral SCC, will present with nystagmus sx during head rotation to both sides during roll test

44
Q

peripheral vs central nystagmus

symptom pattern

A

peripheral - intermittent
* tends to be more peripheral in nature

central - persistent sx
* either peripheral or central

45
Q

how do you differentiate nystagmus in HC from nystagmus of cervicogenic origin

A

HC = BPPV, gravity dependent
cervico = dependent on position of neck

46
Q

a triggering mvmt like reaching for the top shelf would be indicative of BPPV in what canal

A

post SCC

47
Q

a triggering mvmt reading would be indicative of BPPV in what canal

A

ant SCC

48
Q

what pt pop is 3x more likely to develop BPPV

A

migrainers

49
Q

having vertigo with what functional activity makes it 4.3xs more likely to have BPPV

A

vertigo w rolling in bed

50
Q

describe excitation vs inhibition in vertical canals

A

flow of endolymph away from ampulla = excites nerve

flow of endolymph toward ampulla = inhibits

d/t position of kinocilium w/i ampulla

51
Q

what is the primary treatment for BPPV

A

CRP

52
Q

when is Meclizine prescribed and why? what is a consideration for PT with this?

A

prescribed during peripheral event to manage sx of vertigo and motion sickness
* sedative effect on vestib system

sedative effect –> beneficial to not take long term
* if testing a pt, have them hold the med bc can suppress nystagmus

no strong evidence to support use of meds in treatment of BPPV

53
Q

peripheral vs central nystagmus

symptom pattern

A

peripheral - intermittent
* tends to be more peripheral in nature

central - persistent sx
* either peripheral or central

53
Q

what does research say about the efficacy of daily exercise like Brandt Daroffs or Self CRP

A

doesn’t prevent recurrence of BPPV

Adv Neuro: Vestibular (6 decks)

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