Neurological Conditions and Dizziness Quiz

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Questions and Answers

What should be done if a patient cannot actively rotate their neck 45° to both left and right?

Perform radiography. (correct)

Refer for imaging only if high risk factors are present.

Continue with a general cervical spine screen.

Advise rest and follow-up in a week.

Which of the following would NOT be expected if there has been a progression in neck symptoms after an accident?

Neck pain grows and then levels off.

An increase in intensity of existing pain.

Patients report decreased range of motion.

New symptoms develop after an initial plateau. (correct)

Which condition is classified under neurological causes of dizziness?

Multiple Sclerosis. (correct)

Anxiety.

Cardiac disease.

Hypoglycemia.

What type of lesion is associated with CNS tumors?

UMN lesion. Signup and view all the answers

What is one possible vascular cause of dizziness?

Cervical arterial disease. Signup and view all the answers

Which condition is characterized by dizziness lasting under 2 minutes?

Benign Paroxysmal Positional Vertigo (BPPV). Signup and view all the answers

Which symptom is NOT typically associated with intoxication?

Increased focus. Signup and view all the answers

What condition includes dizziness as a potential symptom related to metabolic issues?

Hypoglycemia. Signup and view all the answers

What symptom is associated with vertigo or light-headedness during an ipsilateral head turn?

Visual disturbances Signup and view all the answers

Which of the following is NOT one of the '5 D's' associated with vertebrobasilar insufficiency?

Drowsiness Signup and view all the answers

What condition is characterized by imbalance or unsteadiness related to cervical spine movements?

Cervicogenic vertigo Signup and view all the answers

Which symptom may progressively indicate a later stage of a benign tumor encircling the vestibulocochlear nerve?

Unilateral headache Signup and view all the answers

In which situation might a patient experience severe insufficiency that indicates advanced neurological signs?

When at rest in neutral position Signup and view all the answers

Which cranial nerves are commonly affected by a benign tumor at the cerebellar pontine angle?

CN5 and CN7 Signup and view all the answers

What might be observed in a patient with progressive hearing loss related to a benign tumor affecting the vestibulocochlear nerve?

Tinnitus Signup and view all the answers

Which sign is NOT characteristic of cervicogenic disequilibrium?

Structural abnormalities in the spine Signup and view all the answers

What percentage of patients report experiencing vertigo as a symptom?

50-60% Signup and view all the answers

Which condition is characterized by slow growth and progressive focal neurological signs?

Tumour Signup and view all the answers

What is a key feature that must be present for diagnosing migraine-related vertigo?

At least 5 episodes of vestibular symptoms Signup and view all the answers

What is one potential aggravating factor for vestibular symptoms?

Busy visual stimulus Signup and view all the answers

Which characteristic is NOT associated with headache during vestibular episodes?

Consistent bilateral location Signup and view all the answers

For children with migraine precursor benign paroxysmal vertigo, what is one diagnostic requirement?

5 episodes of severe vertigo Signup and view all the answers

Which condition is identified by hearing loss and aural fullness during attacks?

Meniere’s disease Signup and view all the answers

What type of examination is NOT mentioned as part of the process between episodes in children?

Cardiovascular assessment Signup and view all the answers

Study Notes

Pre-Learning Dizziness

Dizziness is a common complaint, with many causes
Employability skills like problem-solving, communication, and teamwork are developed and enhanced within the clinical neurology module.
Lecture outcomes include understanding dizziness subtypes, common provoking conditions, refining testing methods to identify red flags, formulating key questions for patient evaluation, and correlating dizziness to potential conditions.

Impact of Dizziness

Dizziness has numerous causes (neurological, traumatic, cardiovascular, cerebrovascular, vestibular, and psychogenic).
It significantly affects society, impacting 80% of people over 65 and 85% of those over 85 with vestibular dysfunction.
Age-related changes, by age 75, result in a 35% loss in accurate head movement encoding.

Principles of Dizziness

Light-headedness: Implies a systemic issue like endocrine or cardiovascular problems.
Unsteadiness: Suggests a proprioceptive or movement-related disorder (cerebellum or basal ganglia), indicating a lower-level vestibular center dysfunction.
Vertigo: Indicates a high-level vestibular center issue potentially linked to posterior blood supply issues like strokes.

Principles of Dizziness (Triggered by)

Dizziness can be triggered by head movements, visual stimulation or occur at rest without provocation, which could signify a red flag.
Its duration is crucial. If it lasts a long time, or is severe, it could indicate a serious condition in the peripheral nervous system (e.g., severe vertigo, positional aggravators, episodic occurrence).

What is Dizziness?

"Dizzy" is a layman's term without clinical meaning.
A key question to differentiate diagnoses is: "What does your dizziness feel like to you?"

Types of Dizziness (Major Divisions)

Wobbly (Disequilibrium): unstable feeling.
Whirling (Vertigo): Illusion of spinning or rotary motion.
Weak (Pre-syncope): Lightheadedness or feeling about to faint.

Vertigo - Conditions

Benign Paroxysmal Positional Vertigo (BPPV)
Meniere's disease
Labyrinthitis
Vestibular neuritis
Vestibular migraine
Posterior Inferior Cerebellar Artery (PICA) occlusion
Vertebrobasilar Arterial Insufficiency (VBAI)
Acoustic neuroma

Hallmark Principles of Vertigo

Nausea and vomiting typically accompany vertigo.
Vertigo affects vision.
Head movements may trigger or aggravate vertigo, specific to different disorders.

BPPV

Free-floating otoliths in the semicircular canals inappropriately stimulate the vestibular nerve.
Often caused by calcium crystals.

BPPV - Symptoms

Aggravated by head movement, especially unilateral rotation or extension.
Triggers severe vertigo which resolves within 2 minutes, typically approx. 30 seconds
May experience unsteadiness in between episodes, due to nerve overstimulation.

BPPV - Testing and Treatment

Slow-range head motion tests should not trigger BPPV, while fast movements do.
Arterial red flags should be excluded.
Dix-Hallpike test is often used for diagnosis (delayed onset of rotary nystagmus and vertigo resolving within 2 minutes.)
Treatment generally involves the Epley maneuver.

Meniere's Disease

Autoimmune condition causing overproduction of endolymph in one ear.
Compresses both vestibular and cochlear nerve aspects.
Common onset in the 50s with a higher incidence in Caucasian females.

Meniere's - Early Stage Symptoms

May experience constant or episodic symptoms (hours to days).
Episodes usually last 12 minutes to 12 hours, potentially daily.
Can involve vertigo, aural fullness, tinnitus, balance issues, nausea, vomiting, often accompanied by a history of early-subtle hearing loss.
Has a significant impact on daily activities.

Meniere's - Later Stage Symptoms

Nerve damage with each flare.
Progressive hearing loss and tinnitus.
Increased balance difficulties.
May require hearing aids.
Rehab for balance training may be necessary.

Meniere's - Testing and Treatment

Balance tests (dependent on the disease stage).
Weber and Rinne tests (to assess nerve damage).
Excluding other conditions.
Treatment aims to alleviate symptoms.
Key therapies include reduced salt intake, diuretics, vasodilators, and anti-emetics or nausea medications (surgery as a last resort).

Labyrinthitis

Inflammation of the semicircular canals.
Often affects the cochlea due to proximity.
Multifactorial causes, including viral infections (following upper respiratory tract infections), bacterial infections (following otitis media or meningitis), medications (benzodiazepines, beta blockers, some antibiotics), autoimmune diseases, ear surgery, trauma, etc.

Labyrinthitis - Symptoms

Can have an acute or delayed onset (over several hours).
Typical involves unilateral ear pain and headache, aural fullness and possible discharge, severe and constant vertigo which is aggravated by head movements, fever, hearing loss, and tinnitus.

Labyrinthitis - Symptoms (Continued)

Symptoms last approximately one week, with constant symptoms during this phase.
After inflammation subsides, vertigo and ear pain resolve.
Patients may still experience lingering unsteadiness.
Resolution can take 6-8 weeks.

Labyrinthitis - Testing and Treatment

Temperature assessment
Weber and Rinne tests (sensorineural hearing function)
Cervical AROM (to assess for triggered unsteadiness)
Balance tests (assessing sensory and proprioception)
Treatments are based on the underlying cause, often including anti-emetics, anti-virals, antibiotics, or steroids depending on the cause.

Vestibular Neuritis

Inflammation solely affects the vestibular part of the nerve.
Less common than labyrinthitis and does not affect the cochlea.
Typical onset after 40.
Symptoms can persist for weeks with a longer resolution time compared to labyrinthitis, commonly without hearing loss.

Vestibular Migraine

New form of migraine leading to prolonged vertigo aura.
Vertigo can be simultaneous or separate from a headache.
Headaches are often present in the history.
Common cause identified as spontaneous vertigo.
Relatively high incidence in females.
Typically begins in late 30s or possibly in teens/early 20s.

Vestibular Migraine - Symptoms

Variable dizziness (50–60% report vertigo; others may experience disequilibrium).
Vertigo may be directly associated with head movement.
Visual stimulus can often aggravate episodes which last from 5 minutes to 3 days.
Migraine symptoms may also occur, and are often difficult to distinguish from each other.

Vestibular Migraine - Diagnosis

Ruling out other potential causes (e.g., TIA and PICA, dissection of vertebral arteries, VBAI, tumors, BPPV, Meniere's, cervicogenic problems).
Key to diagnosis are characteristics, including at least five episodic vestibular episodes lasting 5 minutes to 72 hours, present or previous migraine history, and one or more migraine features such as one-sided location, pulsating quality, moderate to severe pain, photophobia, phonophobia, or visual aura occurring during at least 50% of vestibular episodes.

Vestibular Migraine - Considerations for Diagnosis

If no high-risk factors, dizziness is likely benign.
Referral to GP, especially for those over 50, children, or patients presenting with atypical characteristics.

Vestibular Migraine - in children

Benign paroxysmal vertigo of childhood is a migraine precursor.
Diagnosis requires at least five episodes of severe vertigo with sudden onset and rapid resolution (within minutes to hours), without warning, and often accompanies typical migraine pain.
Neurological, audiometry, vestibular function, and EEG tests should be normal during inter-episode periods.
Unilateral throbbing headaches are a possible symptom.

Vestibular Migraine - Management

Addressing lifestyle (caffeine reduction, balanced meals).
Migraine relief (triptans).
Anti-emetics
Pain relief (NSAIDs, paracetamol)
Vestibular rehabilitation therapy.
Chiropractic treatment, particularly for migraine prevention.
Medical care for prevention, including beta-blockers, tricyclic antidepressants, calcium channel blockers, and serotonin antagonists.

PICA TIA/Stroke

Posterior circulatory occlusion, the most common form is Wallenburg's syndrome.
Transient ischemic attack (TIA) should resolve within 24 hours, and the duration is typically around 1 hour.
Permanent neurological damage—neurons.
Incidence greater in males above 55.
Associated with other conditions like diabetes and smoking.

PICA TIA/Stroke - symptoms

Sudden onset of vertigo, Nausea, vomiting, unilateral hemi-ataxia, difficulty with postural control, Horner syndrome (ptosis, meiosis, ipsilateral facial pain, loss of pinprick/temperature sensation), and contralateral body loss (pins and needles, temperature).

Why varied symptoms in PICA

The PICA feeds the cerebellum and lateral medulla.
Damage to the medial lemniscus (sensory) and spinothalamic tracts (temperature and pain perception), and cranial nerve damage can occur.
Ataxia results from an affected cerebellum.

Vertebrobasilar Insufficiency (VBAI)

Atheroma in the vertebral arteries.
One of the most common causes of posterior circulation occlusion.
Can involve a tear in the vessel layer.

Distinguishing between VBAI causes

Atheroma: A buildup of plaque.
Dissection: A tear in the artery wall.

VBAI - Symptoms

Stages of progression, ranging from vertigo/lightheadedness to severe insufficiency with neurologic issues.
Vertigo or lightheadedness on the same side (ipsilateral) as the head turn, lasting as long as the head remains in that position, potentially with visual disturbance.
Experience of lightheadedness or vertigo in the neutral position.
Severe insufficiency, indicated by advanced neurological issues (e.g., ataxia, 5 Ds, 3 Ns).

Vertebral Dissection - Symptoms

Neck stiffness (resulting from arterial inflammation), accompanied by normal neck range of motion.
Ripping or tearing pain in the posterior neck.
Headache, often sub-occipital or directed forward.
New, worst-ever-quality pain.
Ipsilateral vertigo or lightheadedness with head rotation.
Severe cases may experience the same symptoms in the neutral position, plus visual changes.

Atheroma/Dissection - Late-Stage Symptoms

Ataxia
Symptoms involving 3 Ns—Nausea, Numbness, Nystagmus.
Symptoms involving 5 Ds—Dizziness (vertigo or lightheadedness), Dysarthria, Dysphagia, Diplopia (visual abnormalities).
Drop attacks—loss of muscle tone leading to a sudden fall to the floor, without loss of consciousness (may cause loss of consciousness if blood loss extensive).

Atheroma/Dissection - Testing and Diagnosis

Blood pressure recording
Slow cervical range of motion testing (in non-symptomatic neutral positions).
Carotid artery testing
Cerebellar-function tests
Pin-prick testing (for sensory function)
Swallowing test
Assessing for stridor
Cranial nerve examination (cranial nerves 3–12).

Acoustic Neuroma

Benign tumor encircling the vestibulocochlear nerve, one of the more common cerebellar pontine angle tumors that slowly grow over decades.
Typically not detected until the patient is 50+.

Acoustic Neuroma - Symptoms

Early stage: similar to repetitive labyrinthitis, often causing disequilibrium and vertigo, symptoms usually resolving as the nerve adapts.
Later stage: progressive suboccipital headaches, unilateral—Progressive hearing loss and tinnitus, progressive postural instability, leading to vertigo, potential cerebellar signs (ataxia)—on the same side (ipsilateral).—potential impact on cranial nerves 5 and 7.

Acoustic Neuroma - Testing

Weber and Rinne tests (sensorineural loss).
Balance and cerebellar function tests (ipsilateral affect—on the same side as the affected cranial nerves).
Evaluating cranial nerves 5 and 7.

Disequilibrium

Caused by cervicogenic issues, peripheral neuropathy (covered in peripheral nerve lessons), parkinson's disease (covered in movement module), and cerebellar disorders (covered in movement module).

Cervicogenic Disequilibrium

Imbalance or unsteadiness related to cervical spine movements or positions, often caused by a stiff or painful neck.
Damage to the proprioceptors in the neck can disrupt communication to the body's balance center (vestibular system).
SCM and suboccipital musculature prominently involved.
Less direct involvement with joint capsules.
Cervicogenic vertigo, cervical vertigo, and proprioceptive vertigo are related terms.

Cervicogenic Disequilibrium - Symptoms

Unbalance or unsteadiness, often triggered by neck movements or maintained head position.
Duration can range from minutes to hours.
Symptoms often include neck pain or stiffness radiating to the shoulders and/or scapula.
Reduced or painful range of motion (RoM) in the cervical spine.
May make sleeping uncomfortable.
Possible cervicogenic headache.

Cervicogenic Disequilibrium - Diagnosis and Testing

A constellation of signs and a thorough clinical history are essential for diagnosis.
Excluding other possible causes (e.g., trauma red flags, high-risk factors for VBAI, arterial dissection) is crucial.
Auscultation (listening to the carotid arteries for possible abnormal sounds) is necessary to rule out other possible causes.
Careful and measured assessment of the patient’s carotid arteries to help eliminate other causes.
Neurological testing focused on lower cranial nerves, motor and sensory function, eye, speech, and balance (SMR).
Cervical examination to assess for postural adjustments and muscle hypertonicity, range of motion in the cervical spine, and pain/stiffness.
Particular attention to assessing for neurological dysfunction or stiffness without loss of ROM (significant indicator for damage).
Vestibular assessment using the Fitzritson’s test to assess for possible CN8 involvement, evaluating for a positive result in which the head is stabilized and while it is not stabilized.

Canadian C-Spine Rule

Screening tool for deciding if imaging after trauma is required (in patients with potentially high-risk factors).
Step 1: assesses high risk factors (age ≥ 65, dangerous mechanism of injury).
Step 2: determines if indicators of safe range-of-motion assessment exist (e.g., simple rear-end collision, sitting in ED, delayed onset of neck pain, and the absence of midline cervical tenderness and possible evidence of a cervical dissection).
Step 3: assesses the patient’s ability to actively rotate their neck by 45 degrees left and/or right.

Light-headedness

Neurological conditions covered in clinical medicine.
Conditions like cardiovascular, cerebrovascular, and endocrine causes are frequently covered as potential causes.

Homework

Review these slides further and prepare for a consolidation lecture.
Practice case history taking.

Wobbly - Causes of Disequilibrium

Neurological (Multiple sclerosis, syringomyelia, cerebellar disturbances, Parkinson's, polyneuropathy)
Neoplastic (acoustic neuroma, CNS tumors)
Degenerative (polyneuropathy, central myelopathy, dementia)
Intoxication (alcohol/drugs)

Weak - Pre-syncope

Primarily vascular:
- Vertebrobasilar Insufficiency (VBAI)
- Cervical arterial disease
- Orthostatic hypotension (hypermobility, medication)
- Cardiac Issues (e.g. Arrhythmias, CHF)
- Subclavian steal syndrome
- Gastrointestinal bleeds (ulcerated or otherwise)
Systemic issues:
- Intoxication (diuretics, cardiac medications, muscle relaxants, tricyclic antidepressants)
- Metabolic issues (hypo/hyperglycaemia)
- Anxiety, depression (or other issues inducing stress)
- Dementia

Questioning for a Neurological History (I)

Describing dizziness: How does the dizziness feel? (vertigo, disequilibrium, lightheadedness).
Duration of symptoms: How long do episodes last? (seconds to months) - duration of each episode and duration of symptoms;
Onset of symptoms: When did the dizziness begin? (seconds for TIAs/strokes, minutes/hours for BPPV, hours/days/weeks for inflammation related issues, months for acoustic neuromas;
Triggers for symptoms: What causes or worsens the dizziness? (head rotation/positioning, for example)

Questioning for a Neurological History (II)

Triggers for symptoms (e.g., head rotation, visual stimulation, neck movement/position)
Re-evaluation/changes that make symptoms better (e.g., neutral positioning)
Additional symptoms: e.g., neck pain/stiffness, hearing loss, tinnitus, visual changes, drop attacks, ataxia.
Past medical history: any similar incidents, previous illnesses, trauma, or medical conditions.

Post-Lecture Work

Practice thorough cranial nerve examinations.
Prepare notes on neurological anatomy related to dizziness, including interpretation methods for examination findings and possible reasons for abnormalities/changes.

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Description

Test your knowledge on neurological conditions related to dizziness and neck symptoms. This quiz covers various aspects, including causes, symptoms, and classifications associated with dizziness and neck injuries. Challenge yourself with questions that explore diagnosis and treatment options.