A 31-year-old woman with vertigo

Published on 10/04/2015 by admin

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Last modified 10/04/2015

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Problem 45 A 31-year-old woman with vertigo

Timothy Kleinig

A 31-year-old teacher presents to your general practice with a 2-day history of a sensation of the room spinning and unsteadiness while walking. The sensation is continuous and partially relieved by lying down. These symptoms have prevented her from going to work. She feels her hearing is normal and she has no tinnitus. Her only medication is the oral contraceptive pill.

Q.1

What are the principles of assessing a patient with vertigo?

Q.2

How do you differentiate central from peripheral causes of vertigo? What are some causes of each?

On examination she appears fit and well. She is afebrile and her cardiovascular examination is normal. The ear canals and tympanic membranes appear normal. There is no evidence of hearing impairment on clinical testing. Visual acuity testing reveals 6/6 vision on the right but 6/9 on the left. The pupils are symmetrical, but you think there is an afferent pupillary defect on the left. On fundoscopy the left optic disc appears pale compared to the right.

On testing the external ocular movements there is nystagmus on looking to the right and on vertical gaze. The nystagmus is independent of head position and is not fatigable. The remainder of the cranial nerve examination is intact. Limb tone, power and reflexes are normal. However, on finger-nose testing there is an intention tremor of the right arm with mildly reduced coordination.

She recalls having problems taking a photograph using her left eye while on holiday 3 months previously. This had resolved spontaneously over 1 week and she did not pursue the matter.

There is nothing else in the history and from the examination that helped elucidate the cause of the patient’s current problem.

Q.3

How do you interpret this woman’s neurological signs?

Given the probable site of the problem, the patient is referred to a neurologist. Her vertigo had improved but has not resolved completely. Various tests were performed. Figure 45.1A, B was taken from one of the tests.

Figure 45.1

Q.4

Name the investigation and describe the abnormalities.

Q.5

What is the likely diagnosis and what other tests could be done to further support the diagnosis?

The cerebrospinal fluid demonstrated a mild elevation of mononuclear cells, normal protein and glucose and an elevated IgG:albumin ratio. Oligoclonal bands, unmatched in a serum specimen, were detected.

After the diagnosis is made, the patient returns to see you. Her symptoms have largely resolved. She asks what her prognosis is and if any treatment is available.

Q.6

What is your reply?

Answers

A.1 Vertigo is a sensation of movement, typically spinning or rotating, either of the environment or the patient in relation to the environment. This spinning sensation distinguishes vertigo from pre-syncopal ‘dizziness’ which occurs in cardiac arrhythmias, postural hypotension, anaemia or hypoglycaemia. A history of loss of consciousness suggests syncope or epilepsy.

Patients with vertigo present in three main ways: spontaneous onset of persistent vertigo, recurrent vertigo associated with changes in posture, and recurrent episodes of spontaneous vertigo. The major task in the assessment of vertigo is to decide whether the cause is peripheral (related to the vestibular apparatus) or central (vestibular nuclei and connections). Central causes of vertigo are generally more sinister, and a thorough neurological examination is required in patients presenting with new-onset vertigo.

On examination attention should be paid to a full neurological examination looking for focal signs suggesting a central cause. In particular:

• Examine the eyes looking for nystagmus.

• Examine the external ear, including the tympanic membrane and hearing.

You will also need to perform a careful general physical examination.

A.2 Signs suggesting central nervous system involvement include:

• Vertical nystagmus.

• Dysarthria.

• Facial sensory loss.

• Upper motor neurone signs and limb or gait ataxia.

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