Vertigo

Front 1

Peripheral vertigo

Back 1

CN VIII or vestibular apparatus affected

Front 2

Central vertigo

Back 2

Brain stem [vestibular nuclei in medulla and lower pons] and cerebellum affected

Front 3

Peripheral vertigo: differentiating features

Back 3

(1) Sudden onset; (2) Severe intensity; (3) Paroxysmal duration; (4) Frequent nausea; (5) Absent CNS signs; (6) Tinnitus/hearing loss may be present; (7) Nystagmus: torsional/horizontal; (8) Nystagmus is fatigable

Front 4

Central vertigo: differentiating features

Back 4

(1) Slow, gradual onset; (2) Intensity is ill-defined; (3) Constant duration; (4) Infrequent nausea; (5) CNS signs usually present; (6) Tinnitus/hearing loss usually present; (7) Nystagmus may be verticular; (8) Nystagmus is non-fatigable

Front 5

DDx of peripheral vertigo

Back 5

(1) BPPV; (2) Vestibular neuronitis; (3) Labyrinthitis; (4) Meniere's disease; (5) Head trauma; (6) Drug-induced (aminoglycosides, phenytoin, phenobarb, carbamazepine, salicylates, quinine)

Front 6

DDx of central vertigo

Back 6

(1) Cerebellar infarction; (2) Cerebellar hemorrhage; (3) Lateral medullary infarction; (4) Other lower brainstem ischemia; (5) MS

Front 7

Characteristic Story for BPPV

Back 7

First, Pt turns their head - after a few seconds of delay, the vertigo occurs; it will resolve within 1 minute if Pt doesn't move, if you turn your head back, the vertigo occurs in the opposite direction

Front 8

What causes BPPV?

Back 8

Otoliths become detached from hair cells in utricle; otoliths inappropriately enter the posterior semicircular canal

Front 9

Pathophysiology of BPPV

Back 9

"(1) Stop turning head, but otoliths keep moving and drag endolymph. The receptors continue to fire inappropriately and say that the “head is still moving”! The eyes say “head is NOT moving”! The brainsays “room must be spinning in the opposite direction” --> VERTIGO

Front 10

(Modified) Epley maneuver

Back 10

Moves otoliths out of the posterior semicircular canal and back into utricle. Must Remain upright for 8-24 hours; complications - can convert to horizontal canal BPPV

Front 11

Contraindications to Epley Maneuver

Back 11

(1) Unstable heart disease; (2) High grade carotid stenosis; (3) Severe neck disease; (4) Ongoing CNS disease; (5) Pregnancy beyond 24th week gestation (relative)

Front 12

Summary of BPPV

Back 12

(1) Rotatory vertigo (<30 secs) precipitated by head movements; (2) Positive Dix-Hallpike; (3) One treatment is with Epley maneuver. IV phenergan is probably the best ED medication if one is needed

Front 13

Differentiating BPPV from labyrinthitis and vestibular neuritis (VN)

Back 13

(1) BPPV requites head movement, labyrinthitis/VN does not; (2) BPPV lasts seconds, labyrinthitis lasts hours/days; (3) BPPV usually in elderly, labyrinthitis can occur at any age; (4) BPPV has no relation to viral syndrome, in labyrinthitis, viral prodrome precedes; (5) BPPV responds to Epley, Labyrinthitis/VN does not

Front 14

Lab Studies for Vertigo Workup

Back 14

NONE NEEDED! May get Hgb, D-stick, Electrolytes if prolonged vomiting

Front 15

Imaging in Posterior Circulatory Cerebrovascular Events

Back 15

CT is good for cerebellar hemorrhage, but can miss brainstem acute cerebellar infarctions; MRI is much more sensitive than CT for acute infarction with DWI

Front 16

Acute vertigo and dizziness are associated with what type(s) of strokes?

Back 16

(1) Lateral medullary infarctions and (2) Cerebellar strokes

Front 17

Nystagmus due to peripheral causes has all of the following features except: [answer: being horizontal, rotary, or vertical]

Back 17

Peripheral nystagmus is typically horozonto-rotary, not pure horizontal or rotary...and not vertical.

Front 18

Nystagmus due to central causes has all of the following features except: [answer: can be dramatically accentuated by head movement]

Back 18

Vertigo and nystagmus produced by central causes do not significantly worsen with head movement.