Dominic J Mort
23/03/17
Spire Bushey Hospital
“Dizziness”
“Good grief!”
Hx:
“Dizziness”
Pre-syncope
“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:
- falling to right
- nystagmus with his vertigo




No headache
No neck pain
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
Posterior Canal
Utricle
Ampulla
Cupola
Posterior Canal
Cupulolithiasis
Utricle
Ampulla
Cupola
Posterior Canal
Professor Adolpho Bronstein
Hallpike
manoeuvre
Hallpike
manoeuvre
‘Geotropic’ nystagmus
Semont manoeuvre
Easier for older patients
Semont manoeuvre
Semont manoeuvre