Neuro - Vertigo

Front 1

Vertigo definition

Back 1

Sensation of movement of self or objects around self.

Generally with nausea, malaise. Usually a symptom of vestibular system malfunction.

"spinning, tilting, rolling, etc."

Front 2

NOT VERTIGO
Lightheadedness

Back 2

Decreased blood flow to the brain as a whole. As if you will faint.
DDX: Orthostatic hypoTN, cardiac arryth., medications)

Front 3

NOT VERTIGO
Dysequilibrium

Back 3

Proprioceptive dysfunction (e.g. B12 def or peripheral neuropathy)
Cerebellar dysfunction
Motor problem like Parkinson's or even weakness.

Front 4

NOT VERTIGO
Visual dysfunction

Back 4

Poor visual acuity or diplopia

Front 5

NOT VERTIGO
Disorientation

Back 5

Cognitive/perceptual dysfunction.

Front 6

Scarpa's ganglion

Back 6

It is the vestibular nerve ganglion.

Primary bipolar neuron -body is in the vestibular ganglion.

Front 7

Hair cells in semicircular canals

Back 7

Sense movement of endolymph (angular motion)

Front 8

Hair cells in utricle/saccule

Back 8

Attach to otoliths and sense linear movement.


***utricLe, saccuLe for Linear.

Front 9

Central processes of the bipolar cells

Back 9

Constitute the vestibular nerve which runs with the auditory nerve, forming the acoustic nerve (AKA CNVIII).

Front 10

Course of acoustic nerve (AKA CNVIII)

Back 10

Enters skull at internal auditory meatus, traverses the CPA (cerebellopontine angle), enters brainstem at pontomedullary junction.

Front 11

The 4 vestibular pointine nuclei

Back 11

Formed from vestibular fibers. Interconnect with cerebellar (coordination) and spinal systems, CN 3,4,6 (these three ensure that eyes move the right way), and cerebrum (cortex - esp temporal lobe)

Front 12

Accompaniments with vertigo
Nausea (

Back 12

nausea center in medulla triggered bc of sensory conflict)

Front 13

Accompaniments with vertigo
Nystagmus

Back 13

(aberrant activity in commun btwn vestib system and CN 3,4,6 nuclei)

Front 14

Accompaniments with vertigo
Oscillopsia

Back 14

Jumping vision - Due to nystagmus

Front 15

Accompaniments with vertigo

Back 15

Nausea, nystagmus, oscillopsia, diaphoresis, lightheadedness, anxiety, hearing loss, tinnitus (last two are due to information shared byt he cochlear nerve)

Front 16

DDX of vertigo

Back 16

Unusual head movements or positions
Disparity btwn visual and vestibular input (sea or motion sickness)
Spinning

Front 17

DDX of vertigo
(specific syndromes)

Back 17

BPV
Medication effect (aspirin, phenytoin, aminoglycosides)
Vestibular neuronitis/labyrinthitis
Menier's disease
Phobic vertigo
Perilymphatic fistula
Labyrinthine or brainstem ischemia
Meningitis (carcinomatous, TB, fungal, bacterial)
Ramsay Hunt syndrome (zoster infection of geniculate ganglion)
Migraine.

Front 18

Causes of vertigo

Back 18

A-E-I-O-U-TIPS
Alcohol, epilepsy/exposure (heat stroke or hypothermia), insulin, overdose/oxygen def, uremia, trauma, infection, psychosis/poisoning, stroke

Front 19

Benign positional vertigo

Back 19

Due to otoconia settled in cupula of posterior canal (cuprolithiasis) becoming dislodged when head turns quickly.

Front 20

Vestibular neuronitis and labyrinthitis

Back 20

Severe single episode.
Maybe due to inflamm of vestib nerve or labyrinth via a virus.
Tx- symptomatic antivertigo meds and steroids.

Dx clue - Usually not just positional and is self-limited. Often pts just wake up with it.

Front 21

Infectious causes of vertigo

Back 21

Bacterior otitis MEDIA. Results in small neurophysiological subtle changes.

Syphilis

Meningitis - dx clue is headache or other cranial neuropathy. time course is acute.

Sarcoidosis

Front 22

Meniere's disease

Back 22

Associated with sudden falls and sensation of fullness in the ear.
Low frequency hearing loss early on.
Swelling of canals due to excessive endolymph.

Tx - salt restriction, diuretics, weight loss, endolymph shunting, labyrinthectomy, vestibular neurectomy.

Dx clue - hearing loss and tinnitus occurs eventually.

Front 23

Psychogenic vertigo

Back 23

Usually situational (e.g. mall or bridge)

Tx is psychotherapy and meds (benzos or SSRIs)

note - benzos good for other causes of vertigo. So NOT useful for diagnosis.

dx clue - hx of panic attacks and absense of nystagmus.

Symptoms such as sense of doom, paresthesias, hypervent, etc. are helpful but not pathognomonic (characteristic of this disease)

Front 24

Perilymphatic fistula

Back 24

Post-traumatic.
Labyrinth now connects to outside world usually at oval or round windows.

Hyperventilation induces vertigo in some of these pts.

Tx is drainage or shunting.

Still a controversial diagnosis. Exacerbating with cough or sneeze.

Abnormal fluid balance.

dx clue - almost always a hearing loss and a sudden onset after an incident like weight-lifting, scuba diving, forceful nose blowing

Front 25

Labyrinth ischemia

Back 25

e.g. stroke.

Internal auditory artery (from basilar) splits to common cochlear artery (to cochlea) and anterior vestibular artery (to vestibule - ischemia of this will produce only vertigo).

caused by occlusion of basilar artery, AICA, PICA, internal auditory artery (a branch of AICA), or vertebral artery

dx clue - usually other signs of brainstem dysfunction (like facial numbness, diplopia, dysarthria, horners)

Front 26

Wallenbergs syndrome

Back 26

Vertigo, ipsilateral ataxia, dysarthria (motor speech disorder), ptosis, miosis (seen in Horners syndrome too).
Due to PICA infarct

Front 27

Ramsay Hunt syndrome

Back 27

Results from herpes zoster oticus

Causing vertigo, hearing loss, ear pain.

Vesicles present in ear.

Can cause VII palsy (Bell's)

Can track to brainstem and cause encephalitis.

Tx - Acyclovir. Steroids NOT useful.

Front 28

Acoustinc neuroma

Back 28

A cerebelloponting angle tumor. Others are meningioma, epidermoid, cholesteatoma, metastatic tumor.

When a tumor compresses a nerve, there is often more than one symptom!

Front 29

Migraine

Back 29

Vertigo can appear without the headache.

Tx: Proph-cyclic antidepressants, beta blockers, calcium channel blockers, valproate.
Abortive - triptans.

(the vertigo responds to migraine treatment)

dx clue - history of migraine or family history.

Front 30

Taking a history for vertigo

Back 30

Determine if it is imbalance (cerebellar disequilibrium) or a sense of motion (vertigo)

Lightheadedness is not vertigo.

Front 31

Exam of pt with vertigo

Back 31

Orthostatic BP and pulse (along with normal exam)

Thorough head and neck exam with carotids

Otoscopic exam (look for vesibles - Ramsey Hunt)

Full CN exam

Cerebellar exam

Rapid head turning (vetibulo-ocular response - watch for delay in the catch up)

Hall-Pike or Barany (test for verttigo and analyze nystagmus). If the feeling is recreated, there is a peripheral cause of vertigo (in labyrinth or nerve). I think this is associated with BPV? And the ear down side is the labyrinth giving the problem.

Front 32

Nystagmus - vertical vs horizontal

Back 32

Vert - Central vestibular dysfunction (not a labyrinth or CNVIII problem)

Horiz or rotatory - Peripheral vestibular dysfunction

Fast component goes away from the abnormal side.
Patients tend to fall toward to abnormal side.

***fast stuff goes to the abnormal side - fast comp and falls.***

Front 33

Peripheral pattern of vertigo

Back 33

Intense vertigo, short duration, may fatigue with constant stimulation of it, intense naus and vom, nystagmus fixed (doesn't change direction) and horiz or diag, latency for sec seconds with Hall-Pike.

Front 34

Central pattern of vertigo

Back 34

Mild vertigo, may persist, not fatiguing, nausea less common, nystagmus may change direction (including vertical), no latency in Hall-Pike maneuver (immediately occurs)

Front 35

Dx testing for vertigo

Back 35

Audiogram (to asses hearing loss)

MRI - to rule out mass

BSER - measures electrical activity in hearing system. (bestib system parallels hearing system). For early detection of auditory pathway dysfunction.

Electronystagmography - ENG - eye electrodes detecting nystagmus with cold water in canal. Good in differentiation periph vs. cenral vertigo.

VideoNG.

Front 36

BAEP (brainstem auditory evoked potentials)

Back 36

Shows the neural activity of nerves so you can tell where the hearing loss is.

stimulus, AP of CNVIII (cochlear n.), superior olive/nucleus trapezoid body, nucleus lateral lemniscus, inferior colliculus, medial geniculate body, geniculocortical pathway.

Front 37

Vertigo treatment

Back 37

Anticholinergics (meclizine or dimenhydramine [antihistamine] or scopolamine [anticholinergic])

Anti-DA - Promethazine (phenergan) - a neuroleptic (means used to treat psychosis)

Sedative - Diazepam

Front 38

Vertigo, tinnitus, hearing loss associations with each other

Back 38

Can coexist or occur independently.

Front 39

Peripheral lesion sites in vertigo

Back 39

Labyrinths or VIII nerve

Front 40

Central lesion sites in vertigo

Back 40

Vestibular nuclei in brainstem, cerebellum, cortical centers (Temporal especially)

Front 41

Comlpex partial seizure (tornado seizure)

Back 41

Focus presumed to be near the primary vestibular cortical zones (temporal). This sets off vertigo

Front 42

Up-beat nystagmus

Back 42

rapid upward component. lesions at pontomedullary junction

Front 43

down-beat nystagmus.

Back 43

rapid downward component. lesion at craniocervical junction.

Front 44

Barany or Hallpike test

Back 44

During a positive test, the fast phase of the rotatory nystagmus is away from the affected ear, which is the ear closest to the ground.

Used to dx benign paroxysmal positional vertigo

Front 45

Chiari malformation.

Back 45

Chiari malformation is the congenital herniation of the cerebellum through the foramen magnum. There are several types based on associated abnormalities, but it often results in vertigo and occipital headaches. There may be vertical nystagmus and, when severe, dysfunction of long tracts of the spinal cord.

Front 46

Just to be clear:

Back 46

Fast component in horizontal nystagmus tends to beat away from the abnormal side