NEUROLOGY + NEUROSURGERY

ResponsePeripheral vertigo - BPPV, vestibular labrynthitis, vestibular neuronitis, Meniere’s, acoustic neuroma, ear pathology, ototoxicity, barotrauma
Central vertigo - Vertebrobasilar ischaemia/haemorrhage/insufficiency, Vertebral artery dissection, SOL (Cerebellar tumour), MS/Demyelination, posterior circulation migraine, lateral medullary syndrome
Cardiovascular - Hypotension, dehydration, arrhythmia, Presyncope
Other - hypoglycaemia, hypoxia, sepsis, toxin (eg: Alcohol)
Need to know at least 4 of central/peripheral

ResponseParoxysmal
Sudden onset, severe
Vomiting
Worse with head movements
Nausea
Fatigue of symptoms
Tinnitus/hearing loss
Recent viral illness

Negative test of skew (eyes stay fixed on target)
Head impulse = corrective saccade
Horizontal unidirectional nystagmus
Dix hallpike positive

ResponseHistory
Gradual onset, longer duration, less intense
No vomiting
Constant, non fatigueing
Other neurologic symptoms
Absence of positional component
Cardiovascular risk factors

Examination
Head Impulse negative
nystagmus vertical/torsional/direction changing. Non fatiguable/sustained. No latency of onset (<6 seconds after dix), spontaneous
Skew on gaze testing
Cerebellar signs:

• Ataxia - broad based, cerebellar gait. Rhomberg’s positive
• Dysdiadochokinesis
• Past pointing
• Intention tremor
• Dysarthria

Focal neurology

ResponseIntermittent vertigo worse on movement
Lasts seconds-minutes
Ongoing disequilibrium after acute attacks

Normal neuro examination
Positive dicks/hallpike test = fatigable rotary nystagmus

Response= inflammation of vestibular nerve or inner ear
Subacute onset over hours
Persistent symptoms, lasting several days
Hearing loss with labrynthitis

Normal cranial nerve exam
Positive head impulse test

ResponsePast history of migraines, now increased frequency with vestibular episodes
Can occur with/without headaches

Diagnosis of exclusion - normal neuro exam

ResponseHyperacute onset of vertigo
Occipital headache
Difficulty walking, loss of coordination

Ataxia - gait/truncal
Cerebellar signs - past pointing, dysdiadochokinesis,
Head impulse negative, bidirectional vertical nystagmus, positive test of skew

Mgmt
Thrombolysis
Clot retrieval
Decompressive craniectomy
General - BP control, intubation etc.

ResponseSudden onset
+/- hearing loss

Cranial nerve signs
Hearing loss
Negative impulse test

Response=Cerebellar signs
Difficulty with scanning speech/loss of fluency
Nystagmus
Pronator drift
Intention tremor
Past pointing
Gait or truncal ataxia - broad based gait, Rombergs test
Dysdiadochokinesis

ResponseInfarction of the territory supplied by the PICA (posterior inferior cerebellar artery), most commonly related to atherosclerosis of the vertebral artery or PICA itself

Clinically: (in general ipsilateral cranial nerve, contralateral sensory below the face)
Ipsilateral horners syndrome
Ataxia - falls towards side of lesion
Ipsilateral loss of facial sensation (pain + temperature)
Nystagmus - horizontal + rotational
Contralateral loss/change in pain and temperature sensation to limbs
Ipsilateral dysphagia/dysphonia/loss of gag reflex

ResponseCT brain - Time critical if any concerns of vascular event. Assist with potential time critical intervention (Lysis, surgical decompression). accessible, quick, detect large posterior bleed, poor for posterior ciculation assessment/pathology
CTA neck vessels - identify vertebral artery dissection

MRI brain - Useful if central symptoms but normal CT - no radiation, poorly accessible by ED. Sensitive for posterior circulation stroke

ECG
Bloods EUC if vomiting, plt/coags if central cause for ?thrombolysis

ResponseSensitivity 96-100%, specificity 96-98% - ie: Better than MRI!
(note the initial study was done by consultant neuro ophthalmologists - i doubt we get this good in ED)
Indication for HINTS - patients with continuous vertigo and otherwise normal neurological examination. This is because abnormalities in vestibulo-ocular reflex may be the only abnormal neurological finding in patients with cerebellar infarcts.

• ACI

ResponseNormal = no saccade/correction on head provocation (ie: eyes stay on target)- strongly suggests central cause

Abnormal = corrective saccade - consistent with peripheral vertigo as suggests dysfunction of peripheral nerves

ResponseHorizontal nystagmus - suggests peripheral
Vertical deviation/direction changing - Suggests central

ResponseAbnormal skew test with quick vertical gaze correction (Ocular tilt) suggests likely central cause

Normal test = no vertical gaze correction and peripheral lesion