Case vertigo

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Case vertigo

  1. 1. CASE Vertigo Director Anita Sandison
  2. 2. 53 year old male Planning Officer <ul>PC Unwell and dizzy post blueberry and blackcurrant juice <ul>BIBA MIU Bideford 'Stumbled in' </ul>HPC Asymptomatic prior Minutes post consumption-lightheaded <ul>Deterioration over 15 mins, Symptoms related to head movement Nausea and vomiting, Immobile, felt unbalanced Wife noticed slurred speech </ul></ul>
  3. 3. Further questioning <ul><li>Sensation of movement or world spinning around him
  4. 4. No previous episodes
  5. 5. No associated coryzal symptoms
  6. 6. No associated headache
  7. 7. No new onset deafness
  8. 8. No palpitations/chest pain
  9. 9. No history of migraine </li></ul>
  10. 10. Systemic Enquiry <ul><li>No Palpitations, chest pain
  11. 11. Recent Wellman clinic – High blood pressure and cholesterol
  12. 12. PMHx Gout
  13. 13. No medications no Allergies
  14. 14. Exsmoker
  15. 15. Alcohol 7 – 8 units/day
  16. 16. No FHx </li></ul>
  17. 17. Examination <ul><li>Apyrexial, flushed, lying still
  18. 18. Hr 50 BP201/102 rr 12 sats 98%
  19. 19. Cranial nerves </li><ul><li>Nystagmus on far right gaze
  20. 20. Horizontal sustained
  21. 21. Fast towards right ear
  22. 22. No skew deviation </li></ul></ul>
  23. 23. Examination <ul><li>Turning head to each side exacerbated symptoms especially to right
  24. 24. No dysarthria/dysphasia
  25. 25. No dysdiadochokinesis/pastpointing/heel shin negative
  26. 26. Rombergs negative
  27. 27. No ataxia </li></ul>
  28. 28. Investigations <ul><li>ECG Sr 50 </li><ul><li>Borderline LVH </li></ul><li>FBC </li><ul><li>WCC normal but with a neutrophilia </li></ul><li>Urea, electrolytes and glucose </li><ul><li>NAD </li></ul></ul>
  29. 29. Differential Diagnosis Vertigo <ul><li>Peripheral /Benign
  30. 30. BPPV
  31. 31. Labyrinthis
  32. 32. Vestibular neuronitis
  33. 33. Meniéres disease
  34. 34. Superior Canal
  35. 35. dehiscence s Δ d </li></ul><ul><li>Central/Serious
  36. 36. Posterior Fossa Tumours
  37. 37. Brainstem ischaemia </li><ul><li>TIA
  38. 38. Lat Med S Δ d
  39. 39. Wallenberg S Δd </li></ul><li>Cerebellar lesions
  40. 40. Basilar Migraine
  41. 41. TLE aura
  42. 42. MS, syringobulbia </li></ul>
  43. 43. Central v Peripheral SYMPTOM PERIPHERAL CENTRAL Hallucination of movement Definite Less definite Onset Paroxysmal Acute Intensity Severe Moderate Duration Short Long Positional Frequent Seldom
  44. 44. Central v Peripheral SYMPTOM PERIPHERAL CENTRAL Nystagmus present may be present Vegetative severe less frequent Tinnitus frequent seldom Deafness frequent seldom Consciousness preserved may be lost Neurological signs absent present
  45. 45. Cerebellar Pontine Angle Tumours <ul><li>R arely present solely with episodic vertigo.
  46. 46. Vertigo occurs in approximately 20%, but a symptom of imbalance or dis - equilibration is more common
  47. 47. The most common symptoms associated progressive hearing loss and tinnitus.
  48. 48. Look for neurological signs such as a depressed corneal reflex. </li></ul>
  49. 49. Vascular Vertigo <ul><li>Vertebrobasilar Insufficiency
  50. 50. Wallenberg’s syndrome (lateral medullary)
  51. 51. AICA syndrome (lateral pontine)
  52. 52. Cerebellar infarction
  53. 53. Cerebellar hemorrhage </li></ul>
  54. 54. Lateral Medullary Syndrome <ul><li>Complete syndrome: Vertigo with dysphagia, dysarthria, ipsilateral ataxia and facial anesthesia, Horner's syndrome and contralateral body anesthesia
  55. 55. Incomplete syndrome may present with vertigo followed by subtle Horner. Facial and body hypoesthesia. Needs careful examination. </li></ul>
  56. 56. Lateral Medullary S Δ d Dysfunction Effects Vestibular Nuclei Vertigo vomiting nystagmus Inferior cerebellar peduncle Ipsilateral cerebellar findings, ataxia, dysmetria,dysdiadochokinesis Central tegmental tract Palatal myoclonus Lateral spinothalalmic tract Contralateral pain and temperature on body Spinal trigeminal nucleus + tract Ipsilateral pain and temperature on face Nucleus ambiguus Ipsilateral laryngeal, pharyngeal and palatal hemiparalysis Descending SNS fibres Ipsilateral Horner's
  57. 57. Small Cerebellar Infarction <ul><li>Vertigo, unsteadiness and unidirectional nystagmus – Vestibular neuritis
  58. 58. Vertigo with tinnitus and hearing disturbance – Meniere's disease
  59. 59. Paroxysmal positional vertigo – BPV </li></ul>
  60. 60. Clue to Small Cerebellar Infarction <ul><li>Transient headache and blurred vision
  61. 61. Vertigo may disappear but ataxia may progress
  62. 62. Electronystagmography show normal peripheral apparatus </li></ul>
  63. 63. Vertebrobasilar Insufficiency <ul><li>Vertigo is common in VBI
  64. 64. Isolated vertigo was thought to rule out VBI in elderly
  65. 65. Recently many papers have emphasized isolated recurrent vertigo as symptom of VBI
  66. 66. Ischemia of vestibule by AICA and medial cerebellum by PICA
  67. 67. MRA, Angiography BAER may help
  68. 68. In elderly patients with no laboratory evidence of peripheral vestibulopathy or systemic disease, episodic disequilibration or dizziness may be due to vertebrobasilar disease </li></ul>
  69. 69. Conclusions <ul><li>Differential diagnosis – site and cause important
  70. 70. Central cause suggested by H.i.N.T.S
  71. 71. Head impulse ( vestibulo-ocular reflex)
  72. 72. Nystagmus - changing direction/vertical
  73. 73. Test for Skew </li></ul>

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