Neurology Clerkship Week One

Front 1

What are the three presentations of vertigo?

Back 1

Acute severe, recurrent spontaneous, or recurrent positionally triggered.

Front 2

In patients with acute severe vertigo, what type of nystagmus is suggestive of an isolated vestibular nerve lesion?

Back 2

Unidirectional spontaneous horizontal nystagmus

Front 3

How do you know which side the lesion is on in the case of unidirectional SPONTANEOUS horizontal nystagmus in the setting of acute severe vertigo?

Back 3

Lesioned side is the side OPPOSITE the direction of the fast phase.

Front 4

What would you see (in terms of nystagmus) in a pt. with central lesions & acute severe vertigo?

Back 4

Direction changing gaze evoked (nystagmus beats the way the patient looks) or spontaneous vertical (typically down)

Front 5

In positionally triggered vertigo caused by benign paroxysmal positional vertigo, what is the expected nystagmus pattern?

Back 5

Changes direction with changes in head position, most commonly principally vertical, and the Dix-Hallpike test triggers a burst of upbeating and torsional nystagmus for < 1 minute

Front 6

What is the nystagmus finding in positionally triggered vertigo from a central cause?

Back 6

Dix-Hallpike test triggers persistently downbeating nystagmus.

Front 7

If Dix-Hallpike test doesn't work to elicit nystagmus of BPPV, what test can you use, and what variant is probably the cause?

Back 7

Use supine positional testing; cause is probably horizontal canal variant

Front 8

What system does the head thrust test assess?

Back 8

VOR

Front 9

Abnormal head thrust test is highly suggestive of what type of lesion?

Back 9

Vestibular nerve

Front 10

Why is head thrust better than doll's eye test to study vestibular system?

Back 10

Because movements of the doll's eye test can be generated by either the vestibular system OR the smooth pursuit system; head thrust just tests vestibular.

Front 11

What would a normal head thrust test in the setting of vertigo mean?

Back 11

Central lesion vs. vestibular

Front 12

A positive head thrust test when turning head to the right would indicate a lesion on the ____ side?

Back 12

right

Front 13

What is the most common cause of acute severe vertigo?

Back 13

Vestibular neuritis

Front 14

What causes vestibular neuritis?

Back 14

Viral lesion of the 8th cranial nerve

Hint 14

W

Front 15

What are other symptoms associated with vestibular neuritis?

Back 15

nausea, vomiting, imbalance; NOT hearing loss

Front 16

If hearing is affected but picture is otherwise like vestibular neuritis, what is likely diagnosis?

Back 16

labyrinthitis (also presumed viral)

Front 17

Hallmark exam signs (two) of vestibular neuritis?

Back 17

spontaneous unidirectional horizontal nystagmus + positive head thrust to the side of the lesion

Front 18

Treatment for vestibular neuritis?

Back 18

therapy, burst/taper of corticosteroids

Front 19

What's on differential for vestibular neuritis?

Back 19

stroke

Front 20

What is needed to make a diagnosis of Menieres?

Back 20

unilateral hearing loss, which is fluctuating at first, then becomes fixed

Front 21

What signs in a pt. with recurrent spontaneous vertigo would lead to workup of central cause?

Back 21

spontaneous down beating nystagmus or bidirectional gaze-evoked nystagmus

Front 22

Do patients with Meniere's have a positive head thrust test?

Back 22

no

Front 23

What artery might be involved in a stroke that cause auditory symptoms?

Back 23

anterior inferior cerebellar artery

Front 24

Most common cause of recurrent positionally triggered vertigo

Back 24

Benign paroxysmal positional vertigo

Front 25

Key feature of history for BPPV is?

Back 25

movements CAUSE vertigo

Front 26

How long do BPPV attacks last?

Back 26

less than one minute

Front 27

When BPPV particles are in the posterior canal, what signs are seen?

Back 27

burst of upbeat and torsional nystagmus in Dix-Hallpike position with head turned toward affected side

Front 28

When BPPV particles are the horizontal canal, what signs are seen?>

Back 28

supine positional testing will elicit nystagmus in horizontal plane- in direction of head turn or in opposite direction

Front 29

This is rare, but what is the finding of anterior canal BPPV?

Back 29

downbeating positional nystagmus

Front 30

Central lesions can cause nystagmus pattern similar to that of which BPPV type?

Back 30

horizontal canal

Front 31

What drugs could you give acutely for dizziness in ER?

Back 31

benadryl (antihistamine) and anti-nausea meds; could give corticosteroids for long term treatment of vestibular neuritis

Front 32

Where does vertigo localize?

Back 32

vestibular system (inner ear, vestibular nerve, vestibular nuclei), cerebellum, or, less commonly, temporal lobe

Front 33

Brief, isolated, strictly positional vertigo is likely to be?

Back 33

benign positional vertigo, due to inner ear otolithiasis (crystals in the semicircular canals)

Front 34

What is normal result of Rinne test?

Back 34

air conduction > bone conduction

Front 35

What is normal result of Weber test?

Back 35

tuning fork in the middle of forehead- vibration heard equally well in both ears

Front 36

Findings of Rinne test if there is conductive hearing loss?

Back 36

Bone conduction > air

Front 37

Findings of Rinne test if there is sensorineural hearing loss?

Back 37

Air conduction > bone ("normal"), because bone and air conduction are equally decreased

Front 38

Findings of Weber test if there is conductive hearing loss?

Back 38

Vibration louder in affected ear

Front 39

Findings of Weber test if there is unilateral sensorineural hearing loss?

Back 39

Vibration louder in unaffected ear

Front 40

What is conductive hearing loss?

Back 40

Sound not conducted efficiently through outer ear canal to middle ear.

Front 41

What is sensorineural hearing loss?

Back 41

Damage to inner ear (cochlea) or to nerve pathway from inner ear to brain; can't usually be corrected

Front 42

If ataxia is constant, it is likely due to a lesion in the ?

Back 42

cerebellum

Front 43

What is on the differential for a peripheral vestibular lesion?

Back 43

benign positional paroxysmal vertigo, vestibular neuronitis, labyrinthitis, Meniere syndrome/disease, Drug tox, CN VIII lesion from tumor/meningitis

Front 44

What is Ramsay Hunt Syndrome?

Back 44

It's VZV of the geniculate ganglion (facial nerve ganglion with motor/sensory input)

Front 45

Presentation of Ramsay Hunt syndrome?

Back 45

Intense ear pain, vesicles of ear, mouth, face, neck, hemifacial weakness, hearing loss

Front 46

Vertebrobasilar dolichoectasia- what is it?

Back 46

Elongation and distension of artery secondary to chronic hypertension --> can lead to nerve compression

Front 47

Give a differential for central causes of vertigo

Back 47

Migraine, brainstem ischemia, cerebellar mass, complex-partial seizure, MS

Front 48

Positive what test is considered pathognomonic for BPPV?

Back 48

Dix-Hallpike maneuver with problem ear down

Front 49

Why is MRI preference to CT to evaluate brainstem and posterior fossa?

Back 49

bc you get bony artifact on CT

Front 50

What are you doing in the Epley maneuver?

Back 50

trying to move otoliths out of the semiscirculalar canals and into the tricle, where they are asx.

Front 51

What is the treatment of BPPV?

Back 51

meds. usually not indicated