ASSOCIATION OF BRITISH NEUROLOGISTS
ACUTE NEUROLOGY BOOT CAMP 2020
Tuesday 16 June 2020
Diego Kaski, London
The dizzy patient
Learning Objectives
• Identify the clinical signs that help differentiate
central from peripheral vertigo
• Understand how to perform positional
manoeuvres
• Understand the common causes of acute vertigo
Doctor, I’m dizzy…This is the doctor!
Symptoms
• Vertigo: Illusion of movement
rotational or ‘true vertigo’
“like a merry-go-round”
• Dizziness, giddiness, unsteadiness, light-
headedness, imbalance…even headache!
• Nystagmus = involuntary eye oscillation
Vestibular Disorders
BPPV
Brief attacks of vertigo (<30 seconds) provokedTriggers: turning in bed, lying down, head extension, or bending over
Symptomatic episodes for weeks to months, asymptomatic intervals for months to years
Dix-Hallpike
Treatment Epley’s or Semont maneouvre
Sideways Hallpike – ‘right ear down’
1 2 3
Semont repositioning manoeuvre for right sided BPPV
Treatment
• Cinnarazine
• Stemetil Not longer than 3 days!
• Prochloperazine
Encourage mobility
Vestibular physiotherapy
Prognosis
Predictors of poor recovery (Cousins, Kaski et al. 2017)
“…We found that worse outcome was predicted by
higher levels of acute visual dependency and
autonomic arousal …but not with vestibular
variables.”
Persistent Postural Perceptual Dizziness
Central or peripheral?
HINTS to infarct
Head Impulse test
Direction changing Nystagmus
Skew deviation
Kattah JC, Talkad AV, Wang DZ, et al. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside
oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke 2009;40:3504–10.
Who needs a scan?
Vertigo with normal Hallpike and:
cranial nerve or limb signs
New onset headache
Acute hearing loss
Intact head impulse test
Migraine
• History of migraine
• Migraine symptoms during vertigo attack
• Hearing usually spared
• Motion sensitivity
• Response to conventional treatment
Vestibular migraine
Unexplained ‘dizziness’ in the elderly
Dizziness affects 30% of people > 65yrs (Dros et al., 2011)
The symptom complex of subjective unsteadiness and postural light-headedness, without any rotational vertigo, often reported by elderly patients (Hopkins, 1993; Ahmad et al., 2015).
Normal extensive battery of neurological and neuro-otologicalassessments, their dizziness remains “unexplained”.
Ahmad et al. J Neurological Sci 2015
To ‘v’ or not to ‘v’
NOT ALL ‘DIZZIES’ ARE VESTIBULAR
* Arrhythmias
* Presyncopal episodes
* Orthostatic hypotension
* Anaemia
* Hypoglycaemia
* Psychological
Answers
• Betahistine
• Bithermal calorics
• Cawthorne-Cooksey exercises
• Dix-Hallpike manoeuvre
• Referral to stroke team
• MRI brain
An 67-year-old hypertensive lady complains of unsteadiness for the last 3 months.
She has mild nausea but no vomiting. Routine examination reveals no nystagmus
but she staggers when walking.
What is the most appropriate next step?
Answers
• Acute vestibular neuritis
• Labyrinthitis
• Meniere’s disease
• Posterior circulation TIAs
• Vestibular migraine
• Vestibular Paroxysmia
• Benign Paroxysmal Positional Vertigo
An 67-year-old hypertensive lady complains of recurrent episodes of unsteadiness
and internal rocking sensation lasting several hours for the last 6 months. She has
mild nausea and occasional vomiting, together with photophobia. Routine
examination including Dix-Hallpike is normal.
What is the most likely diagnosis?
Answers
• Direction-changing nystagmus
• Gaze-evoked nystagmus
• Abnormal Head Impulse test
• Skew Deviation
• Associated hearing loss
• Normal hyperacute MRI brain
An 67-year-old hypertensive lady complains of acute vertigo, unsteadiness, and
diplopia.
Which of the following does not suggest a stroke?
Take home messages
• Perform a Dix-Hallpike manoeuvre in all patients
presenting with dizziness or imbalance
• Consider the HINTS criteria in patients with
acute prolonged vertigo
• Test bedside hearing in patients with acute
vertigo (red flag!)
http://dizzinessandbalanceworkshop.co.uk
ASSOCIATION OF BRITISH NEUROLOGISTSACUTE NEUROLOGY BOOT CAMP 2020
Week 2
15 June 7 – 8 pm Stroke - Dr Akram Hosseini, Nottingham
16 June 7 – 8 pm The Dizzy Patient - Dr Diego Kaski, London
17 June 7 – 8 pmAcute neuromuscular weakness - Dr Aisling Carr,
London
18 June 7 – 8 pmSurviving your first year as registrar - Dr Alex Foulkes,
London
Association of British Neurologists, Ormond House, 27 Boswell Street, London WC1N 3JZ
Email: [email protected]. Telephone: 02074054060