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: info@abn.org.uk. Telephone: 02074054060