Dominic J Mort 23/03/17 Spire Bushey Hospital

Dizziness Good grief!

Hx: Pre-syncope Dizziness As if you might faint? Vertigo Mostly about this As if on a merry-go-round? Non-rotational commoner than spinning Ataxia As if drunk? Not when sitting down

Case 1 38 F, mother of 3 For at least 6 months Days when feel very dizzy. Occasional waves of feeling, like being on a boat Other days not too bad More sensitive to motion sickness Movement of escalator make feel worse Otherwise well Occasional headaches since teens. Normal neurological examination Normal physical examination

Migrainous dizziness Commonest cause of recurrent dizziness Bouts may last hours to days to weeks. Symptoms vary True spinning vertigo unusual Often there is a background of non-simultaneous headaches May be other migrainous symptoms (nausea, photophobia etc) Propranolol 10 mg bd (increasing as tolerated); Amitriptyline; Pizotifen Reassurance!! Lifestyle changes. Relaxation exercises.

Case 2 31M taxi-driver Woke up 5AM, acute severe vertigo Vomiting ++ Wife called for ambulance

Case 2 Acute vestibular signs: No headache No neck pain - falling to right - nystagmus with his vertigo No other focal neurological signs Partial improvement over 3 days Labyrinthitis

Acute labyrinthitis = Vestibular neuronitis / Acute idiopathic unilateral peripheral vestibulopathy Commonest cause of acute vertigo lasting >24 hours Cause uncertain - probably post-infectious, immune-mediated Onset over mins - hours. Intense vertigo (horizontal) + vomiting Patient prefers to lie flat in bed. Symptoms even with eyes shut. Acute unilateral vestibular dysfunction. Nil else focal. Symptoms settle over days (to weeks) brainstem compensation Antiemetics (Cyclizine, Betahistine, Stemetil etc.) 2 weeks Encourage to mobilise when safe helps recovery. May need physiot

Case 3 55 M Fell off a ladder banging his head. A&E home 3 weeks later: Turned over in bed to silence the alarm clock Severe spinning of the room

Case 3 55 M Fell off a ladder banging his head. A&E home 3 weeks later: Turned over in bed to silence the alarm clock Severe spinning of the room Felt very nauseated. Vomited x 2 At worst for 3 mins. Signficantly better after 15 minutes Felt unsteady and nauseated all day 5 days later: Lying back in bed talking to his wife Same symptoms of nausea and dizziness, mild vertigo Next 6 weeks, intermittently Having to avoid lying flat on his back Recurrent waves of unsteadiness when moves his head Now feeling a lot better, but not back to normal

Examination Normal eye movements. No nystagmus Normal coordination Normal gait. Can tandem walk. Romberg s negative Unterberger s test: Equivocal Hallpike manoeuvre: Positive for the Left Left BPPV

Benign Paroxysmal Positional Vertigo (BPPV) Commonest cause of acute rotational vertigo. Usually positional trigger: Turning in bed. Lying back. Sitting down. Last few seconds to minutes. But disequilibrium may last longer. Most spontaneous. Also common after head trauma / immobility Repeated attacks. Positional dependence may fade. More symptomatic in patients with pre-existing vestibular impairment Diagnosis: Hallpike / Semont manoeuvre. Epley or Semont manoeuvre: 80% curative. Or vestibular exercises

Case 4 42M Uzbekistani businessman, visiting UK On toilet, ringing then deafness L ear As tried to walk to bed, developed acute vertigo. Vomited Noticed could not co-ordinate L hand in order to phone for help.

Case 4 Acute (left) vestibular signs: - nystagmus to right - impaired left VOR No headache No neck pain BUT Complete deafness L ear Left cerebellar ataxia Not labyrinthitis

Left AICA stroke

Effects of chronic cerebral vascular changes Whilst cerebral small vessel disease, rarely causes dizziness or vertigo, it can undermine the normal central compensation mechanisms that permit recovery from labyrinthitis or BPPV. Small vessel disease also undermines confidence walking.

Causes of recurrent paroxysmal vertigo Common: BPPV Migraine (vestibular migraine) Anxiety attacks (usually with hyperventilation) Very rare : Superior canal dehiscence syndrome (SCDS) Vestibular paroxysmia (neuro-vascular cross-compression) Paroxysmal brainstem symptoms in MS Epileptic vestibular aura

Understanding re-positioning manoeuvres for BPPV

Posterior Canal

Posterior Canal Utricle Cupola Ampulla

Posterior Canal Cupulolithiasis Utricle Cupola Ampulla

Posterior Canal

Hallpike manoeuvre Professor Adolpho Bronstein

Hallpike manoeuvre

Geotropic nystagmus

Semont manoeuvre Easier for older patients

Semont manoeuvre