PD neuro conditions based on dizziness sx

how do consider dizziness?

• focus on history, onset, duration, aggravating/alleviating

• look at description: faint, falling, passing out, off balance, unsteady, spinning

what are associated symptoms of dizziness?

vision changes, difficulty speaking, trouble walking, URI symptoms, palpations

what does lightheadedness suggest?

pre-syncope

what are common causes of lightheadedness?

• vasovagal stimulations

• orthostatic hypotension

• arrhythmias

• medication side effects

what is vertigo associated with?

vestibular disease

what are common causes of vertigo?

• labyrinthitis

• meniere’s dz

• benign positional vertigo (BPPV)

what is the most important consideration for dizziness?

if this is peripheral (benign) or central (dangerous) in origin

• is there a true loss of consciousness?

• any prodromal sx?

• length of symptoms

• was the event witnessed

what peripheral issues can cause dizziness?

• syncopal episodes

• orthostatic hypotension

• benign paroxysmal positional vertigo (BPPV)

• labyrinthitis

• meniere disease

• acoustic neuroma

• drug toxicity (sudden or gradual) like loop diuretics, aminoglycosides, salicylates, ETOH

what is vasovagal syncope associated with?

fear, strong emotion, pain, prolonged standing, hot env, palpitations, nausea, vision changes

→ dec in BP and inc in HR

sudden onset of sx w/ quick recovery

what is cardiovascular syncope caused by?

• arrythmias: palpitations

• aortic stenosis: chest pain, SOB w/ exertion

• MI: angina pain

• massive PE: chest pain, tachypnea, SOB, anxiety

what is orthostatic hypotension?

dizziness that can be seen with position changes

dizziness is more “near syncope” instead of spinning

what are common associated sx of orthostatic hypotension?

• lightheadedness

• palpitations

• fatigue

• vision changes

what is included in inner ear?

cochlea, semicircular ducts, vestibulocochlear nerve

structures that are located behind the middle ear

what is the epidemiology of benign paroxysmal positional vertigo? (BPPV)

• incidence inc w/ age

• women > women

what causes BPPV?

caused by otolith displacement within the semilunar canals/ducts

(most common in posterior canal)

what is BPPV?

• recurrent vertigo sensations that last 1 minute or less

• provoked by head movements

what is BPPV assoc with?

N/V

what is BPPV NOT associated with?

NOT associated with hearing loss

how do you diagnose BPPV?

witness nystagmus during provoked movement

dix-hallpike maneuver (lower patient’s head to see if there’s nsytagmus, positive test = vertigo, wait 15 seconds sometimes it doesn’t immediately happen)

what is the BPPV treatment?

• epley maneuver (lay down head tilted back 30 degrees, turn right and left, then turn your body and head is facing down, sit back up)

• avoid sudden movements

what BPPV tx does not usually help?

• meds don’t really help d/t short duration of episodes

what is labyrinthitis?

inflammation of the entire CN VIII

unilateral hearing loss

what is vestibular neuritis?

inflammation of the vestibular portino of the CN VIII only

NO hearing loss

what can cause labyrinthitis and vestibular neuronitis?

viral/post viral inflammatory process, idiopathic

what is the presentation of labyrinthitis and vestibular neuronitis?

rapid onset of severe vertigo w/ N/V and gait instability

gait will lead toward affected side

what are the PE for labyrinthitis or vestibular neuronitis?

• nystagmus can be suppressed with visual fixation

• positive head impulse test

• gait instability toward affected side

• neuro s/sx normal

• possible temp hearing loss/tinnitis

what is the head impulse test?

• pt picks static target and stares in the area. when head turned to the side, the eyes should remain on target but then might look to the side you’re yanking their head = positive

what is meniere disease characterized by?

episodic vertigo, tinnitis, ear fullness, and hearing loss

what causes meniere disease?

endolymphatic hydrops of the labyrinthine system of inner ear

has hearing loss! (unlike a lot of other ones)

when does meniere disease typically begin?

20-40 years of age

what are the sx of meniere’s disease?

• vertigo is spinning, N/V that can persist from 20 mins-24 hours

• hearing loss can flucuate and often affects lower frequencies → permanent hearing loss

how do diagnose meniere’s?

• 2 or more spontaneous episoes of vertigo that last from 20 mins-12 hours

• documented sensio-neural hearing loss in affected ear

• fluctuating aural symptoms (tinnitis, ear fullness)

• sx not related to anything else

• could detect low frequency hearing loss with audiometer

• no specific test

how do you evaluate hearing loss?

1. start with gross hearing and determine if there is an affected ear

2. you can follow up with weber and rinne test to determine if hearing loss is conductive or neurosenory

what is conductive hearing loss an issue with?

• problem with external or middle ear

• impairs sound of inner ear

what are possible causes of conductive hearing loss?

• foreign body

• otitis media

• perforated tympanic membrane

• otosclerosis of ossicles (the ONLY conductive hearing loss you cannot see during otoscopic examination)

what is sensorineural hearing loss?

inner ear problem that effects transmission of nerve impulses to brain

what can cause sensorineural hearing loss?

• loud noise exposure

• inner ear infections

• trauma

• acoustic neuroma

• congenital/hereditary disorders

• aging

• meningitis

• meniere’s

what is the weber test?

• place 512 hz tuning fork on head

• if the sound is lateralized (one ear hears better = conductive loss, if sensorineural loss = sound goes to the non-affected side)

what is the rinne test?

• use 512 hz tuning fork

• compare air conduction to bone conduction, put on mastoid bone, when they can’t hear it anymore, put it on the ear. if they can hear it now when they couldn’t before, that means AC > BC

• conductive hearing loss: air conduction = or < BC

• sensorineural hearing loss: AC > BC

when would you want to use weber and rinne tests?

for unilateral hearing loss

what is acoustic neuroma?

AKA vestibular schwannoma

• slow growing tumor that causes imbalance of vestibular output that is compensated by CNS

what are sx of acoustic neuroma?

imbalance or tilting

(true vertigo is rare)

unilateral hearing loss (slowly p rogressive)

tinnitis

how do you evaluate acoustic neuroma?

• consider for asymmetric sensorineural hearing loss

  • exam: hearing loss

how do you diagnose acoustic neuroma?

audiometry

• MRI - well circumscribed, enhancing lesion in the middle ear with extension into cerebellopontine angle (“ice cream on a cone”)

what central issues can cause dizziness?

• brainstem lesion

• atherosclerosis

• MS

• TIA
  CVA

• vertebrobasilar migraine

what is vertebrobasilar migraine often associated with?

ataxia, diplopia, dysarthria

what is the circle of willis?

everything comes together to preserve blood flow

what is cerebrovascular accident (CVA) RFs?

AKA stroke

• age (doubles every decade after 55)

• HTN

• smoking

• hyperlipidemia

• DM

• obesity

• ETOH use

• a-fib

• carotid artery disease

• obstructive sleep apnea

what are the anterior cerebral arteries?

branches of internal carotid arteries, supplying the anteromedial aspect of the cerebrum

• not commonly affected

• provides blood flow to front and parietal love

if a pt has anterior cerebral arteries issue, how might they present?

leg problems: contralateral leg weakness and sensory loss → evaluate LE strength and sensory

affects frontal lobe → behavioral/personality abnormalities

what is the middle cerebral arteries?

continuation of internal carotid arteries, supplying most of the lateral portions of the cerebrum (goes through parts of broca’s area)

what is the most common artery to be involved/affected by a stroke?

middle cerebral arteries

what might you see if the middle cerebral artery is impacted?

contralateral face, arm, leg weakness, sensory loss, visual field loss, aphasia (caused by contralateral motor and sensory loss)

+sensory deficits

MAKE SURE to check strength, UE/LE + sensation

what can cause strokes?

• occlusion to middle cerebral artery (most common)

  • visual field cuts

  • contralateral hemiparesis

  • sensory deficits

• occlusion of left middle cerebral artery → aphasia

• occlusion of right middle cerebral artery → inattention to opposite side of body

what is involved in the posterior circulation?

vertebral artery and basilar artery

when it comes to posterior circulation suspected issue, what should you do?

look at visual fields, check occipital lobe (vision), cerebellum

if the vertebral artery is damaged, what might you see?

dysphagia, dysarthria, ataxia

if the basilar artery is damaged, what might yo usee?

oculomotor deficits, ataxia

what are posterior cerebral arteries?

branches of the basilar arteries, supplying both the medial and lateral sides of the cerebrum posteriorly

what does a posterior circulation problem result in?

contralateral visual field loss and vertigo

what is a transient ischemia attack (TIA)?

• transient episode of neuro deficits

• caused ischemia to brain, spinal cord, or retina without infarction or tissue injury

how long do symptoms typically last for TIA?

< 1 hour

what is the #1 risk factor for TIA?

HTN

what is the presentation of TIA?

• focal neuro deficits that present similar to stroke (depending on artery)

• amaurosis fugax (sudden, temporary loss of vision in one eye)

what is the PE for TIA?

• symptoms are temp, so you usually don’t see them

• auscultation of carotid arteries to evaluate for bruits

• possible irregularity of murmur on cardiac exam

what is the workup for TIA or CVA?

• CT brain WITHOUT contrast #1 (Rule out hemorrhage)

• CT or MRI with contrast

• carotid doppler

what is the HINTS exam?

• head impulse (test for labyrinthitis)

• nystagmus

• test of skew

what type of nystagmus most commonly seen with peripheral causes?

horizontal nystagmus

what does torsional or vertical nystagmus suggest?

central pathology of some sort (spec. vertical → central cause of vertigo)

what is the test of skew?

• instruct pt to look at your nose and then cover one of their eyes

• quickly move your hand to cover the other eye and observe the uncovered eye for any vertical/diagonal corrective movement

• repeat with other eye

what is multiple sclerosis?

most common immune mediated inflammatory demyelinating disease of CNS, most common is RRMS

what is epidemiology of MS?

women > men

young adult

what do the sx of MS look like?

• sx begins hours to days → gradually remit over weeks to month (can be focal or multifocal in presentation)

what are common signs and sx of MS?

• sensory symptoms in limbs/face

• visual loss

• acute/subacute motor weakness

• diplopia

• balance problems

• vertigo

• bladder problems (75% urgency)

• cognitive impairment

• pain

what might you see on PE of MS?

• evidence of UMN signs (Hyperreactive DTR, present babinski, clonus, spastic weakness/paralysis)

• lhermitte sign

• nystagmus

• intentional tremor

• gait disturbance

what is lhermitte’s sign?

shock-like sensation down back or/limbs with flexion of neck

what causes the intentional tremor in MS?

problems to the motor cortex

what is the work up for MS?

• clinical: 2 distinct episodes of CNS deficits at diff CNS location

• MRI of brain/spinal cord: with and without contrast → hyper-intense white matter plaques

• CSF eval can be done if MRI neg

what are other things not mentioned that can cause dizziness?

hyperventilation, hypoglycemia, hyperglycemia, seizures

what should you do next if you think a pt has a stroke?

• neuro consult, CT of brain, EKG, labs (CBC, CMP, cardiac enzymes)