Dizziness And Vertigo

Front 1

vasovagal syncope

Back 1

autonomic surge – results in excessive vasodilation and bradycardia at same time

Front 2

Acute cerebellar dysequilibrium:

Back 2

Suspect a cerebellar issue if pt has gait or truncal ataxia.

Could be due to stroke, hemorrhage, mass, demyelinating disease, inflammatory disease, infectious/postinfectious disease, INTOXICATION.

Front 3

Subacute to chronic proprioceptive dysequilibrium:

Back 3

Suspect if loss of position sense, display of Romberg sign.

Could be due to B12 deficiency, Tabes dorsalis (syphilis), cervical spondylosis w/myelopathy, or neuropathy.

Front 4

Chronic extrapyramidal abnormalities leading to dysequilibrium:

Back 4

Conduct the pull test to see if pt has them.

Parkinson's--chronic postural instability.

Front 5

Vestibular neuronitis/Labyrinthitis:

Back 5

-Usually following viral syndrome
-Acute onset vertigo, nausea, vomiting, worse with head movements, symptoms diminish over days to weeks
-Neuronitis: no hearing loss
-Labyrinthitis: hearing loss (cochlea involved)
-Labyrinthitis – hearing loss can be permanent, mild to moderate, usually for higher frequencies (>2000 Hz)
-20-30% cases can recur
-Often occurs in kids.


-Treatment: time, antiemetics, meclizine, vestibular exercises
-Labyrinthitis can be infectious - bacterial (suppurative, needs antibiotics/surgical treatment), viral

Front 6

Ménière's Disease:

Back 6

-Vertigo, nausea, vomiting, hearing loss… again
-Recurrent, episodic attacks (30 min to few hrs)
-Typically presents in 5th decade of life, ?FHx
-Hearing loss is progressive, for low frequencies, patient have sensation of pressure/fullness in ear

-Due to intermittent increase in endolymph production/ volume, distention of labyrinth
-Unusual factoid: nystagmus can beat TOWARD the lesion – pressure stimulates nerve

-Treatment:
-Low-salt diet, diuretics, occasionally steroids, rarely decompressive surgery can help vertigo, not hearing loss

Front 7

Acoustic Neuroma:

Back 7

-Not really a “neuroma” – actually a schwannoma along 8th nerve, or at cerebellopontine (CP) angle
-Patients can complain of unsteadiness (dysequilibrium) or vertigo
-Can progress slowly.
-Tinnitus and hearing loss usually first symptoms
-Workup for unilateral hearing loss often involves MRI to rule this out
-Treatment is surgical – radiosurgery, conventional
-Meningioma at CP angle produces same picture
-Note for USMLE Step I: If you see bilateral CP angle tumors = think Neurofibromatosis type II

Front 8

Benign Paroxysmal Positional Vertigo:

Back 8

-The most common cause of vertigo in adults
-Sudden onset vertigo (severe), nausea/vomiting, triggered by movement.
-Short latency period (seconds) after head movement before onset of vertigo <1 minute, then symptoms improve until next mvmt
-Patients feel worse lying on affected side, better when still
-Torsional, unidirectional nystagmus, worse with abnormal ear down

-Mechanism: otolithic debris in semicircular canals stimulate hair cells – esp. posterior canal
-Can be spontaneous, from head trauma, or from utricle degeneration in elderly pts.

Front 9

You diagnose BPPV using:

Back 9

The Dix-Hallpike maneuver. Elicits the torsional, unidirectional nystagmus.

Front 10

You treat BPPV using:

Back 10

The Epley Maneuver. Rolls the otoliths off of the hair cells.

Front 11

Causes of central vertigo:

Back 11

Acute: Ischemic stroke, intracranial hemorrhage, vertebrobasilar insufficiency

Subacute or chronic: mass

Front 12

Acute cerebellar infarct or hemorrhage:

Back 12

-Often presents with acute vertigo, nausea, vomiting, sometimes with headache.
-Flocculonodular complex contains vestibular connections – PICA distribution infarct
-These are emergencies.
-Skull is a “closed box” – swelling and blood can cause elevated intracranial pressure in the posterior fossa (smaller than anterior fossa). If 4th ventricle closes off (swelling, blood), hydrocephalus occurs

Front 13

Signs of acute cerebellar infarct or hemorrhage:

Back 13

-Patients sway or fall toward the lesion… though peripheral vertigo patients can also do this.
-Nystagmus a feature.
-Would also expect some gait ataxia
-Stroke presenting as vertigo alone very uncommon

Front 14

Vertebrobasilar Insufficiency:

Back 14

-Intermittent vertigo with other “brainstem findings”
-Brainstem at risk for infarction
-Due to vascular disease of posterior circulation – uncommon disorder, resulting in hypoperfusion and ischemia of brainstem structures – causing transient brainstem symptoms
-Somnolence with vertigo is an ominous sign – pontomesencephalic reticular formation or bilateral thalami

Front 15

Basilar Migraine:

Back 15

-Vertigo with nausea and vomiting can be a migraine equivalent. Can have brainstem signs or symptoms as well.
-May or may not occur with headache, photo- and phonophobia.
-Motion sickness can be a predictor.
-Symptoms last minutes - few hours.
-If no headache, this is a diagnosis of exclusion after a patient has had recurrent attacks – without accompanying hearing loss or tinnitus – over years.
-No confirmatory tests