LESIONS

A Guide to Localisation in Neurology

Case 5. Acute vertigo and unsteadiness

Outcome

The patient was admitted and given anti-emetics. A CT head was unremarkable. Despite the reassuring signs, due to his vascular risk factors an MRI was performed, which was normal. He was reveiwed by the neurology service who diagnosed vestibular neuritis.

The intensity of his nausea and vertigo settled quickly and he was able to be discharged home.

In the following 2 weeks he reported lingering dizziness, mainly on moving around, and had not gotten back to his baseline level of activity. He was encouraged to keep active to enable adaptation and recovery – and avoid getting into a pattern of avoiding movement to prevent discomfort. He was given exercises to try as part of vestibular rehabilitation.

He did his best to push through the discomfort, resuming work and exercise - and after 2 months he felt completely normal again.

Acute vertigo with right-beating horizontal-torsional nystagmus and failure of the left vestibulo-ocular reflex, due to left-sided vestibular neuritis

1. The standard neurological examination sequence is important in vertigo, but is not enough – examine the eyes!
2. Assessing the vestibulo-ocular reflex, nystagmus, and testing for skew deviation distinguishes peripheral and central causes of vertigo with high accuracy if done properly
3. If there is no spontaneous nystagmus, try removing fixation. If it emerges, this can suggest a peripheral cause
4. People can recover quickly from the acute phase of vestibular neuritis but often have lingering symptoms in the following weeks. It is best to encourage movement and avoid prolonged use of vestibular sedative medications to enable the system to recover