Vertigo

Aphasia

A vertebrobasilar transient ischemic attack is characterized by the sudden onset of one or the more of the following symptoms and signs .Paresis (1,2 or 4/limbs), drop attacks, numbness of involved limbs and face, impaired vision (Diplopia or Bilateral visual field defects) vertigo, nausea, dysarthria and ataxia. Aphasia is a feature of Carotid artery transient ischemic attack.

Benign paroxysmal positional vertigo (BPPV):

• It is characterised by vertigo when the head is placed in a certain critical position. There is no hearing loss or other neurologic symptoms.
• Disease is caused by a disorder of posterior semicircular canal though many patients have history of head trauma and ear infection
• It has been demonstrated that otoconial debris, consisting of crystals of calcium carbonate, is released from the degenerating macula of the utricle and floats freely in the endolymph
• The condition can be treated by performing Epley’s manoeuvre. The principle of this manoeuvre is to reposition the otoconial debris from the posterior semicircular canal back into the utricle.
• The manoeuvre consists of five positions.

1. Position 1; With the head turned 45°, the patient is made to lie down in head-hanging position (DixHallpike manoeuvre). It will cause vertigo and nystagmus. Wait till vertigo and nystagmus subside.
2. Position 2. Head is now turned so that affected ear is up.
3. Position 3. The whole body and head are now rotated away from the affected ear to a la teral recumbent position in a face-down position.
4. Position 4. Patient is now brought to a Sitting posiition with head st ill turned to the unaffected side by 45°
5. Position 5. The head is now turned forward and chin brought down 20°.

Basilar migraine [Ref: CMDT 09 p. 849]

• It is a case of Basilar migraine
• Since it was believed to have originated in the basilar artery it was earlier called basilar artery migraine, but the absence of consistent evidence for basilar artery involvement lead to renaming as Basilar migraine only.
• Basilar migraine is characterized by aura comprising of a bewildering variety of signs and symptoms of the visual cortex and brain stem.

– Basilar migraine mimicks ischemic strokes of the brainstem and the posterior cortical regions.

• The aura which lasts for 10-45 minutes usually begin with typical migrainous disturbance of vision and is characterized by : ?

– Visual symptoms in both the temporal and nasal_, fields.

– Dysorthria

– Vertigo

– Tinnitus

– Decreased hearing

– Double vision

– Ataxia

– B/L paresthesia

– B/L paresis

– Decreased level of consciousness

• After the aura is over a severe throbbing occipital headache supervenes.

• Splenomegaly may be the initial presenting sign 
• Aquagenic pruritus
• Hyperviscosity leads to vertigo, tinnitus, headache, visual disturbances, and transient ischemic attacks (TIAs). 
• Systolic hypertension is due to red cell mass elevation. 
• Venous or arterial thrombosis may be the presenting manifestation of PV. 
• Erythromelalgia, is a complication of the thrombocytosis
• Hyperuricemia with secondary gout, uric acid stones, and symptoms due to hypermetabolism can also complicate the disorder.

It mainly occurs in young females and children, frequently in context with a family history of other forms of migraine.

It clinically manifests with bilateral visual symptoms associated with vertigo, ataxia, tinnitus.

Weakness and peripheral dysaesthesias and sometimes other brainstem and occipital lobe symptoms.

This is followed by severe, throbbing, posterior bilateral headache.

Ref: Benign childhood partial seizures and related epileptic syndromes — Chrysostomos P. Panayiotopoulos, Page 304

Benign paroxysmal positional vertigo (BPPV) is vertigo that is precipitated by head position. It can be precipitated by trauma, but often no precipitating factor is identified. It generally abates after weeks to months. On exam, patients display nystagmus and the symptoms can be reproduced by head movement. In addition, the symptoms show latency, fatigability and habituation.

Benign paroxysmal positional vertigo (BPPV) is characterised by vertigo when the head is placed in a certain critical position.

There is no hearing loss or other neurologic symptoms. Disease is caused by a disorder of posterior semicircular canal.

The condition can be treated by performing Epley’s manoeuvre.

The principle of this manoeuvre is to reposition the otoconial debris from the posterior semicircular canal back into the utricle.

Benign paroxysmal positional vertigo (BPPV) is vertigo that is precipitated by head position. It can be precipitated by trauma, but often no precipitating factor is identified. It generally abates after weeks to months. On exam, patients display nystagmus and the symptoms can be reproduced by head movement. In addition, the symptoms show latency, fatigability and habituation.

• Vertigo precipitated by the movement of head in a specific direction: Benign positional vertigo.
• Intermittent brief vertigo with occasional drop attacks, ataxia, visual loss, double vision and confusion:  Vertebrobasilar insufficiency.
• Episodic recurrent vertigo, with auditory symptoms, headache, photophobia and aura: Migraine.
• Vertigo with facial weakness and loss  of taste sensation: Ramsay hunt syndrome.
• Triad of episodic vertigo, tinnitus and progressive deafness: Meniere’s disease.

Ans. is ‘a’ i.e., Hypomagnesemia

All the above given metabolic abnormalities except hyperammonemia is seen in TPN, however the symptoms mentioned match with those of hypomagnesemia.

Ans. is a i.e. Positional vertigo 

Benign paroxysmal positional vertigo (BPPV) is characterised by vertigo when the head is placed in a certain critical postion, and can be treated by Epley’s maneuver.

The principle of this maneuver is to reposition the otoconial debris from the posterior semicircular canal back into the utricle. After maneuver is complete, patient should maintain an upright posture for 48 hour. Eighty per cent of the patients will be cured by a single maneuver.

Answer. is B (Basilar migraine)

Repeated episodes of throbbing occipital headache in association with ataxia and vertigo in a young female with a positive family history of headache suggest a diagnosis of basilar migraine.

Dizziness, vertigo and ataxia heralding an intense throbbing (occipital) headache are typical features of basilar type migraine

Diagnosis of Basilar Migraine is suggested by age, female gender, positive family history and attacks of headache with vertiginous aura provoked by usual migraine triggers

Basilar Type Migraine (subtype of migraine with aura)

• Basilar type migraine describes recurrent attacks of migraine with aura in which symptoms suggest a brainstem origin (including vertigo & ataxia)
• The onset of Basilar type migraine is typically before 30 years of age and peaks during adolescence
• There is a distinct female preponderance with girls more frequently affected than boys in a ratio of 3:1 (majority of sufferers are girls )
• Family history of migraine is frequent
• Unlike other types of migraine headache may be occipital in origin

‘Vertigo & Disequilibrium: A practical guide to diagnosis and management’ by Weber (Thieme); ‘Handbook of Headache (Lippincott- Williams)’ 2nd/214

Practical Neurology’ by Biller 3rd/15

Ans. More common in Japanese people, who are usually positive for HLA-B27

Ans. B: Subjective sense of imbalance

In vertigo, patient gets a feeling of rotation of himself or of his environment.

Vertigo (“a whirling or spinning movement”)

• It is a type of dizziness, where there is a feeling of motion when one is stationary.
• The symptoms are due to a dysfunction of the vestibular system in the inner ear.
• It is often associated with nausea and vomiting as well as difficulties standing or walking.
• The most common causes are benign paroxysmal positional vertigo, concussion and vestibular migraine while less common causes include Meniere’s disease and vestibular neuritis.
• Excessive consumption of ethanol (alcoholic beverages) can also cause notorious symptoms of vertigo.
• A number of conditions that involve the central nervous system may lead to vertigo including: migraine headaches, lateral medullary syndrome, multiple sclerosis
• Vertigo is a sensation of spinning while stationary.
• Repetitive spinning, as in familiar childhood games, can induce short-lived vertigo by disrupting the inertia of the fluid in the vestibular system

Vertigo is classified into either peripheral or central depending on the location of the dysfunction of the vestibular pathway

Peripheral:

Vertigo caused by problems with the inner ear or vestibular system is called “peripheral”, “otologic” or “vestibular”.

– The most common cause is benign paroxysmal positional vertigo (BPPV) but other causes include Meniere’s disease, superior canal dehiscence syndrome, labyrinthitis and visual vertigo.

– Any cause of inflammation such as common cold, influenza, and bacterial infections may cause transient vertigo if they involve the inner ear, as may chemical insults (e.g., aminoglycosides) or physical trauma (e.g., skull fractures).

– Motion sickness is sometimes classified as a cause of peripheral vertigo.

Central:

If vertigo arises from the balance centers of the brain, it is usually milder, and has accompanying neurologic deficits, such as slurred speech, double vision or pathologic nystagmus.

– Brain pathology can cause a sensation of disequilibrium which is an off-balance sensation.

Ans. is ‘A’ i.e., Prochlorperazine

Labyrinthine suppressants used in vertigo

They suppress end organ receptors or inhibit central cholinergic pathways in vestibular nuclei.

These are :‑

1. Antihistaminics (with anticholinergic action) – cinnarizine, cyclizine, dimenhydrinate, diphenhydramine, promethazine.
2. Anticholinergics- atropine, hyoscine.
3. Antiemetic phenothiazines-prochlorperazine, thiethylperazine.

Ans. is ‘a’ i.e., Tullio phenomenon

Hyperacusis refers to sensation of discomfort or pain on exposure to normal sounds. It is seen in injury to nerve to stapedius and in case of congenital syphilis (Hennebert sign).

Displacusis is a condition where same tone is heard as notes of different pitch in either ear.

Paracusis willisii is a condition where patient hears a sound better in presence of background noise. It is seen in otosclerosis.

Tullio phenomenon is a condition where the subject gets attack of vertigo/dizziness by loud sounds.lt is seen in labyrinthine fistula and after fenestration surgery.