Vertigo and Nystagmus - Clinical approach part-2.pptx

Clinical approach to vertigo and nystagmus based on Dejong's Neurological examination text book

1. Vertigo and Nystagmus - 2 Yasser A. Alzainy Al-Azhar University

2. Agenda Nystagmus “and other ocular oscillations ” Classification of nystagmus Physical examination in dizzy patient Central causes of dizziness Peripheral causes of dizziness 20XX Presentation title 2

3. Nystagmus “and other ocular oscillations ” Classification Non-neuropathologic Nystagmus Neuropathologic Nystagmus Nystagmus mimics

4. Nystagmus Rhythmic Biphasic

5. Classification 20XX Presentation title 5 Pendular vs Jerk Spontaneous vs Induced Physiologic vs Pathologic Other Specifiers Rapid / Slow Coarse / Fine Manifest / Latent Horizontal / Vertical / Torsional

6. Grading 20XX Presentation title 6 1 st degree Only in eccentric gaze 2 nd degreee In primary gaze 3 rd degree Even upon gazing towards the slow phase

7. Alexander Law 20XX Presentation title 7 Jerk nystagmus increases in the direction of the fast phase

8. End-point nystagmus 20XX Presentation title 10 At extremes of lateral gaze Down to as little as 30º in some normal individuals Low amplitude Irregular Variably sustained Symmetrical Dysconjugate (Abducting > Adducting eye) Can be abolished

9. Optokinetic nystagmus (OKN) 20XX Presentation title 11 Striped drum / tape; Mobile App Ask the patient to “count” the stripes PTOJ mediates pursuit When ready to break off, signals ipsilateral FEF to generate a saccade Fast phase opposite tape movement Localizing Value Occipital vs Parietal lobe (optic radiation) Normal OKN vs Blunted / Absent

10. Induced vestibular nystagmus 20XX Presentation title 12

11. Voluntary nystagmus 20XX Presentation title 13 High frequency Irregular Low amplitude Pendular Cannot be sustained for long (>30 s) Eyelid twitches

12. Congenital nystagmus 20XX Presentation title 14 Since infancy Horizontal Even in vertical gaze Null point Head tilt Damps with convergence Holds what he reads extremely close Inversion of OKN

13. Ocular Disease Blindness-induced nystagmus Spasmus nutans 20XX Presentation title 15

14. Spontaneous nystagmus 20XX Presentation title 17 Diminish by visual fixation Possible triggers (vestibular): Mastoid tapping Hyperventilation Head Shaking

15. Positional nystagmus 20XX Presentation title 18 Dix-Hallpike Maneuver ~= BBPV in the posterior SCC of the dependent ear Wait until symptoms subside Assess for recurrence Nystagmus is torsional and geotropic

16. Central positional nystagmus 20XX Presentation title 19 No latency Vertical (upbeat / downbeat) If torsional component (rare) = ageotropic Persists > 40 s or even as long as position is maintained Vertigo, Nystagmus , Nausea mismatch

17. Dix-Hallpike Maneuver 20XX Presentation title 20

18. History items 20XX Presentation title 21 Central Peripheral Nausea Variable Variable “more prominent ” Positional Rare Common Diplopia, dysarthria, dysphagia Common Rare Long tract dysfunction Common Rare Hearing loss, tinnitus Rare Common Imbalance Variable, often severe Variable, often mild/moderate Oscillopsia Severe Mild Recovery Months Days-weeks Recurrence Rare Variable

19. Examination items 20XX Presentation title 22 Central Peripheral Neurological Signs: “ Cr.N . dysfunction {strabismus, dysphagia}, weakness, sensory loss” Common Rare Nystagmus Vertical or horizontal Multidirectional : Gaze-evoked Dysconjugate No suppression with fixation Torsional or horizontal Unidirectional Conjugate Suppresses with fixation Head Impulse test Maintains fixation (NL) Catch-up saccade (Impaired) Alternate cover testing Skew Deviation No skew deviation

20. 20XX Presentation title 23

21. Ocular movements with high localizing value

22. Downbeat nystagmus Upbeat nystagmus

23. Rebound nystagmus Convergence retraction nystagmus

24. Bruns’ nystagmus Seesaw nystagmus

25. Ocular Bobbing

26. Opsoclonus Ocular Flutter

27. Central Causes of Dizziness

28. Central Causes of Dizziness Cerebrovascular disorders Multiple Sclerosis Migraine Seizure CPA tumors Cranio-cervical junction disorders Other: Cerebellar degeneration / Cerebellitis , Hereditary ataxias, Psychiatric. 20XX Presentation title 32

29. Cerebrovascular disorders 20XX Presentation title 33

30. Multiple Sclerosis 20XX Presentation title 35 Can mimic peripheral (root entry zone) INO Pendular nystagmus

31. Cranio-cervical Junction disorders 20XX Presentation title 40 Symptom worsen w/neck extension & cough Spontaneous & positional vertigo, tinnitus, hearing loss, dysarthria/dysphonia, ataxia Shortness of neck, low neck hair line , limited neck ROM Lower CN signs May develop hydrocephalus

32. Peripheral Causes of Dizziness Vestibular Neuritis Meniere's Disease Benign paroxysmal positional vertigo

33. Benign paroxysmal positional vertigo 20XX Presentation title 47 Most common cause of vertigo Canalithiasis 85-95% in posterior canal (5-15% in horizontal) Brief (<1 min) spells provoked by Δ s in position +ve Dix-Hallpike maneuver (80% sensitive and specific). Spontaneous recovery after weeks, but may recur Treatment with reposition maneuvers: Eply maneuver and habituation exercises ( Brandt- Daroff )

34. Vestibular Neuritis 20XX Presentation title 53 Vertigo and nystagmus last for hours / days Mimic posterior circulation CVA No hearing loss or other neurological symptoms Post- or Para-infectious (e.g., HSV) Unilateral hearing loss may implicate labyrinthitis MRI + DWI is a must if CVA risk factors Subsides in weeks, but may recur Steroids can be used within days from onset

35. Meniere’s disease 20XX Presentation title 54 Caused by endolymphatic hydrops. Recurrent attacks of vertigo lasting >20 min Horizontal rotatory nystagmus, hearing loss (may remain between attacks) Sense of fullness and/or tinnitus V ertigo often severe w/ days of disequilibrium/N/V often progresses to bilateral

36. Thank you 20XX Presentation title 55 Yasser A. Alzainy