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still wait. We are live. Hell. I brought, uh, welcome, Teo. It's that welcome to this week has been on for today with Well, would you like to be joined again by that's Jamie Talbot, a registrar extra in the Southwest. Ah, and he's gets was three birthday as always. A lot content is, that's for if you look through the previous weapons on the metal websites, you'll be up to see records it as well as on YouTube on. Then keep an eye out because we've got sort of three or four more questions coming up. We've got one on Monday on acute stroke. And then the week after we got one traumatic brain injury. We'll finish on front of the 20th elliptical infection, and then we're gonna take a little break. But we try and work out what other neurology webinars we want to do. As always, you can get feedback. You feel like feedback. You get stuck a few portfolio on, everything is better belong, catch up. Well, as I've said so, Jenny, Maybe to you, But in thanks very much I'll just beat up my presentation. Have a so hey, everyone concede that. Okay, Yeah, that's Yeah, that's available. So? So the topic of my talk is ah, Vertigo. A systematic approach. Um, on down. There will be some multiple choice questions and voting later on, so I'll just stick this sticker session number up on the screen. Now, um, if people want to go again, um, looking out for about 30 seconds or so, Um, I thought about the talk. In the meantime, um, we see, So I'm a gentle but one of the neurology registrars in Exeter. Um, and we see quite a lot of patients presenting with vertigo. Um, on, But, um, although I guess ent specialist probably a bit more affair with them, Some of the diagnosis and management. So the the talk will probably be a bit polarized towards, um, How we see things as a neurologist. And you know what? How we kind of make clinical decisions and, you know, diagnostic clues and what's important to us. Hopefully you'll be useful to tell you as well. Um, say vertigo or dizziness. Um, I think the first thing when it comes to people describe in their symptoms is feeling dizzy is that there are ah lot of different connotations and a lot of different words that people used to describe completely different symptoms. These are probably the most common off those descriptions, even though there's many more. Dizzy and Gideon particular are the two terms, which was a while kinds of confusion and have all kinds of different meetings. Um, so as a case in point, I'll start with a case study 80 80 year old woman presented to the emergency department after a fall at home. She reported a four week history or feeling giddy when walking in between room rooms in her house, culminating in a full and an ambulance being called medications included. Bendroflumethiazide is up so ramipril and simvastatin. On examination, she had a couple of beats of gaze, UH, voting stagnants on testing I movements and was slightly unsteady and cautious on her feet. A BP was 105 over 70 with a heart rate of 70 BPM. She was quite pale and had allowed ejection. Systolic murmur a blood to reveal the sodium of 124 anemia of 90 um, so I think that is just a example of them. The many different reasons that someone can complain of giddy or dizzy? Um, you know, low sodiums anemia, low BP. Um, So, um, so I think, um, it's very easy to kind of slip into the, uh, problems of what people actually mean. So when we talk about vertigo, specifically, we mean a sense of movement, either internal or external movement. Um, and the common descriptions people give a spinning, um, you know, like that just come off around about, um, although also any kind of movement swaying, tilting, fearing, being poor toe one side being on a ship. Is it common? Um uh, coming descriptions of movement, although in themselves, very different entities. Um, so a good question that you can, I ask is do you mean that everything was moving around? You're that you felt you might part out because I was probably to, um that's the, uh, distinguisher. If people are actually experiencing vertigo where they're they're experiencing lightheadedness or presyncope. Um, so of, uh, this is a systematic approach to dizziness rather than vertigo. But I think the first point is to know your enemy and to know what people are talking about when they describe dizziness or getting us. Um, and a lot of people advocate the these four general symptom descriptions, Teo, to describe how people are feeling. So for today the world's moving disequilibrium, which is a more of a feeling of unsteadiness, lightheadedness. My head's swimming, um, and precinct appears I'm going to pass out. Um, and even those descriptions aren't perfect, and they kind of blur into each other. But a very good. So the groundlings toe to think about traditional vertigo is caused by things affecting the vestibular system. Or alternatively, you have central causes affecting this cerebellum brain stem. Um, so things like this people isis and BPPV many years, um, disequilibrium again. It's more kind of general, all those things that can also cause a couple of general feeling of them unsteadiness rather than frank vertigo. Um, but again, you're sort of getting into the territory of other causes of things. Like for for neuropathy, where people feel unsteady on their feet and a taxi or balance problems. Um, and then there's this, um, this is just keep ppd, which is basically I am, um I will three p. D. Um, it's basically kind of this perception of the dizziness, um, and a lot people get lose their confidence because of these feelings, and, you know that just kind of makes it feel unsteady in its own right. Lightheadedness is often drugs and low soldier in that hypoglycemia stuff like that. And sometimes there could be anxiety component in the mix and precinct. Be generally thought of this things where the there's an interruption of the blood supply. So if I usually cardiac vasovagal orthostatic mechanisms um, um, so getting the first day, I think the second question, um to ask is Is it episodic core? Is it continuous? Um, and if it's short lived with clear provoking factors, especially head movement, it's probably BPPV. BPPV is the most common cause of vertigo and typically causes, you know, shortly of vertigo with them precipitating movements. So if it's, um, if it's triggered by sort of things like sitting up, um, you know, turning in bed, um and then it sort of lost about 30 seconds. Goes away is probably BPPV. Um, and you don't have to think too much more. Um, so the third question in the in the systematic approach and this is probably the most difficult one on, it's Ah, this is a question for vertigo, which is kind of persisting. That's kind of come on and it's it's ongoing. Is is it central, or is it peripheral? Um so central means that there's a problem within the substance of the brain or the brain stem. Um, on peripheral means that it's something within the vestibular system. So within the, um, the labyrinth and the at the stem circle canals or the nerve, um, in terms of questions that I do, my asked to kind of narrow down. Whether something central peripheral peripheral vertigo, they often say, is more severe. Um, again, a wheeze factors and questions are not perfect. That's a kind of a general rule of thumb, which is often this proof. Are they older or young? Obviously, if they're very old, you're gonna have a much lower threshold. Think about stroke if they're still in the thirties, stroke or something very low. Um, any associated cranial nerve symptoms, things like days paresis, facial weakness, bulbous symptoms, things that would point to essential cause, um, in the history to they have a history of recurrent vertigo. Um, and that's quite important, um, again thinking about things like the steep that migraine if there's a repeating pattern of these attacks is obviously some more. Extrovert is usually a one off, but this'll that migraine could be repeating entity, um, and then thinking more broadly, was there a trigger to the vertigo upside So often? Um, there isn't a trigger. Um, but something's can precipitate this tablet problems. And, uh, the culprit gentamicin is a culprit for causing these sort of problems. So if there's any recent antibiotic courses for gentamicin, um, again, think about the ears and hearing loss. Any tinnitus? Um, I guess you'd be thinking along the lines of many years labyrinthitis acoustic in your right, Um, that's goes usually quite a rare symptom of acoustic neuroma in almost 9% of cases. Um, the key symptom of acoustic neuroma recent, you know, slow hearing loss. So, um uh, so it's not a common cause for 30 day, um, they have a history of migraine or especially migraine with aura to suggest that this could be my goodness, um, neck pain or injury. It's the dexa getting vertebral dissection of stroke. And again, any recent head injury. Head injuries, very common causes of the first go usually kind of clears up flavor appeared of months afterwards. Um, head injuries, um, you know, dislodge a lot of them stones otoliths. And they can cause BPPV. And sometimes you can actually have a decent off. You know, bone can come separating cause of vertigo due to a superior canal dehiscent. So those are some from useful questions Kind of come up with in the history to kind of refine the diagnosis of it. Um, then the clinical examination is very helpful with the caveat that although the clinical signs are, um, not perfect on down there very often, um, differential, differentiating peripheral in central causes. Um, you might see the same things in either. But there are some general principles which can help in it down. Um, in terms of the clinical examination, nystagmus is important. Looking at the nystagmus again, doing a full cranial nerve exam to check if there's any obvious brain stem cerebellum, signs of Danish symptom, um, and then the hints exam of which nystagmus is a component. But I'll I'll talk about that in a bit. Um, so I've got a lot of videos coming up, which I've, um, basically commandeered from the internet with, um trying to go credit the source is better. I think it's useful to see some of the clinical signs so that you know what What you're dealing with. Um, So, um, I'll change this video, that you have a look at it and then I haven't talked about. Okay, so I'll play the video again and just talk the same time. So the stagnants could be five, um, in different ways. Um, off the stack. Usually when we talk about any stagnates were talking about some jerk nystagmus where we have a slow phase fast phase the slow fe slow drift across the one side on that, you know, do to the disruption of the Evista. You know, whatever circuits, and you see the fast foods that correctives a cards where my comes back across on, that's the last phase is is basically the what we refer to is the direction of the nystagmus, um, onda direction of staggers, congee, horizontal, or it can be tortured allow. As in this video, um, if you look carefully at the video because the eyes are basically kind of rotating, Robbins are necessary. Um, picking in one particular direction or two horizontally. There's this rotation in to them. So this is described that sort of torsion or component of the nystagmus. You see it more in the right, right clip. Their the army is just kind of irritating. Slightly anti clot quiet. See on it could be quite difficult to appreciate, sometimes better if you see to push in on the stagnants. That is usually a good indicator that the next Agnes is peripheral terms. On dumb, however, that that's usually perform the status is usually it's a kind of a mixture of some torsion, all nystagmus mixed in with a horizontal nystagmus, and in this video is really kind of just a rotational. But I thought was a good video for just kind of showing you what what you mean when, say torsion, all rotational nystagmus, the way it kind of rotates around? Um, so this is a horizontal nystagmus, and seeing the phase the direction of stagnant is very important, and you can, um, give you a bit of a clue as to weather the weather. The problem central or peripheral. So the trap in this's video has, um, unit directional stagnant. So don't be putting him in one direction, which is to the left, so you can see they're stagnant in the primary position There the eyes. That's kind of beating to the left. You see the fast face to the left. He looks to the left on the except of ineffectiveness centuries, and it's still beating to the left. Um, hey, look's to the right. And even there, you can see the fast face is moving to the left hand side. So it's only really going in one direction. Um, on, um, you need direction this time. This is them again. Hints a bit more towards it being a peripheral problem. Um, rather than a central problem. This, on the other hand, is, um, by direction of the stagnancy, looking to the right, you can see the fast pace and stagnant speaking to the right, and she looks over to the left. Hand's tied on. You can see that the thighs, it beating to the left, looking to the right eye's a beating to the right. I was excited to the left. This ankle Is it going to the hand side so changes direction on? That would be more indicative of a central cause. Um, like this one's a bit subtle, but this shows down. Be honest of us. Um, so again, this patient's eyes there's no horizontal complaining that the eyes are just kind of beating down with, um, And if you see horizontal nystagmus stagnant and if you sorry, vertical nystagmus and particularly down beating a stagnants, um, that is much more suggestive of a central cause on. But certainly it. If you saw this patient you saw the next and it's beating down with you would be much more concerned about something like multiple sclerosis or or some sort of century mediated in this bag mess. Um, so I mentioned the hints exam here on on. This is kind of an add on to the normal clinical examination. Um, hidden Spacey stands for head impulse, test nystagmus and test of skew on there. Kind of, um, 33 different things that can give you some idea about whether a problem is peripheral, whether it's central, um, so and I'll show you some videos of that. The most useful of those test is probably the head impulse test, Um, on. But I'll go into detail now, So this is, um, we'll start with a test of skew. So So this is how you test for it. Basically, you got someone to fixate on. Then you're just moving the hand, Um, covering each eye in, turn on, switching across. Um, um, so no. So I think it looks like that's a normal test is very I can see, but, you know, she's a bit far away. Um, so how you test it? This is, um, example. A positive test. Cover the left up, and then you can see that there's a corrective Sicard off the right arm. I pay that again. Okay. The right eye. No real change there in the left eye. And you could see the eye Recaredo the alignment of the eye. So that is, um if you see that with someone with the vertigo symptoms that would be more suggestive of a central problem, stroke or s or something like that. However, as a test, it's it's not perfect on. Do a lot of people have, you know, just squints and latent strabismus and which this test can pick up a swell. So so again, it's a it helps it. It can kind of help in the in the clinical thinking, but it's a test it's it's far from perfect. This is an example. The head impulse test. This is probably more useful, so, and this is how it's performed. You are so patient to keep their neck nice and lax to keep their eyes on your eyes, and then you're quickly moving in the head back one way or the other. So if you see it's his head to moving quickly to the right, then there's another A gets move quickly to the left. Does know that movement. I could move into the right on. This is a This is a positive test here again, you can see it's the left. I'm sorry. Moved the head to the right. There's a corrective Sick are see cause C B. I's kind of catch up there. Not so much movement when he does it to the other side. And if you watch again, moves it quickly to the right with me, I just catch up. Um, so that's a positive test on indicates the implicates, the because the eyes catching up when he rapidly moves the head of the right. It's implicating the vestibular apparatus on the right side, so it's kind of AM AM suggestion of a peripheral vestibular problem on the implicates, the right, the stapler apparatus. This is an example just up the head impulse test, where it seems to be normal. It's a bit more difficult to see this one. I think that, um if you keep it on the eyes, there isn't really a corrective. It's a card saying overnight we always basically remain fixated on the target on does know sort of correction there. So that's a a normal test. That's what you'd probably see in your eye. I do think that as people get older, people can develop a bit of the stupidest servants that sometimes you do see your positive tests again as a test. It can't be free. Be relied on for, um, But again, it's a another. It is a useful information that can help honing in on on the problem. All right, so So I will proceed by a few of these voting grounds. Basically, you've got the AP up, but I will bring up the voting in a sec. So this is the first case. Um, 37 year old athlete acutely developed symptoms of rotational vertigo on getting up one or one morning lasting a matter of minutes before Philly resolving, However, he suffered further attacks, particularly on looking up quickly bending down or turning in bed with significant nausea. You have a history of migraines but was otherwise fit him well. Basic neurological and physical examination did not reveal any abnormalities, so it's just close up. Ah, Sale. Uh huh. Say, know it's quick. So I give people bit of time just to, um, to vote on this one. Just hide the polls. Said they want to buy a cent ones opinion. Okay, so we have a look. Um, So the majority of you chose BPPV Onda? Uh, that is the correct answer. Who's, um, say the nine parts is more positional vertigo. Um, so this is, um this is a personal problem. This is, um, characterized the symptoms by short lived attacks of vertigo on often with provoking movements. Um, and it relates to, um you've got within the the ah, the vestibule. Beautiful. The usual, in fact, that you've got, um, basic little crystals. Little stones, which were embedded in a kind of matrix of the matrix. Basically on. They can, uh, dislodge, and they can end up in in these canals? Um, you've got three canals. You upped the, uh, hysterical. Which kind of just off in a bit of an angle. Um, horizontal canal, which is gonna be in playing with the horizontal plane on the superior Canal. Um, on gum. The yes, the crystals can get dislodged into one of these canals, usually the posterior canal Onda um on they basically disrupt the vaguely They stimulate the hair cells, which are kind of sensing the movement of the fluid in there, and they kind of set of the activated. The result is a feeling of vertigo and, you know, and stagnants that you can observe. Um, the, um, as I said, the majority relate from stones in hysteric. Now on the horizontal can now accounts for the majority of the others. About 5 to 30% on the superior can. Now is really very rare. Cause of them be they. That's picture of just what the You know what it looks like of the stones. There is something called cheaper, loose. I assess where you can get these Krysten. The Deborah can kind of stick to the cupula that space of this pretty print out the the Ampyra, which basically stopped stones coming out. It's kind of blocking the path of it so they can stick to that on. They could be a bit more difficult to treat. Um, on da. Well, then they can be with That's Cubillas scientist. We get out the camel, a scientist where we actually end up within the semicircle canals, of course, problems there. So the diagnosis, the diagnostic test, whichever one you know is about to to test for BPPV, it's addictive point test, and this is a test off the posterior canal. So they, um, see it The patient up on the bed turn the head 45 degrees towards the air being tested. Um, And then you said, Bring the head down quickly so that the head's just overlying the couch on. Then you're sitting. Observe. Ask the patient, keep your eyes open and observe for any nystagmus. Um, Onda, you had a positive positive test If the if it not just provokes symptoms and this darkness birth provokes the appropriate stack. Ms. Um, you tend to have these, um, these four things which, uh, which helped, Which you should see in this when doing this maneuver latency So there's a kind of periods, usually the second or two before the development of symptoms. Um, torture know and upbeat directionality. Um, you remember I told you before that the, you know, upbeat nystagmus is usually am an indicator of, um, a central problem. But obviously the head is a different angle here. So, um, the stagnant that you tend to see relating to these canals is is usually it's in the is in the plane of the canal. So it's That's essentially why you have to retake the hit 45 degrees in this test because you're kind of pointing my head towards, you know, to be in line with that come out to provoke the most, um, symptoms. Um, so you see this kind of talks no nystagmus, um, which is beating up with, um Onda, Um ah. And then, um, but the state must think reverses if you come up on dot So you see this particular city. So if you repeat the if you repeat the test several times, you'll see the effect diminish with each subsequent test. Um, so this is a video of a positive dix Hallpike tests. Um, you see, there's a bit of latency. The eyes move and again you can see there's that sort of torture ality to see that irritation. But there's also this comes during the statin. It's beating upwards. That's I mean, that kind of all settles down after that. Um, um, you know, bring about two things. So it comes down to the left. Is testing the left arm of late. Even the Ms diagnose build up, she gets symptoms, and then you can see that the always have them. I'll be in the start ms with this, um, um, rotational component to it a minute signals down eso That is a positive test on indicative off left posterior canal. Be be be be. Um so, um, the if you do diagnose posterior canal BPPV um, the, uh they're maneuvers, which could be curative. Um, on the well known one is the Epley maneuver. Um, play the video is to see what the site. So you turn the head to be symptomatic side. So if it's left can only turn head to the left, bring that dumb, keep it up half a minute between the steps, turn the head to the right one. When the head And then the body turns on the right hand side again. Another 30 cents to a minute or so. I'm in. Come out like now I play that one more time. Just the same concern Head comes to the left. Left Now come down quickly. So that's really the same as addictive Pike that then it comes across to the right outside and again. This is just repositioning because I'll time to try and get the debris to move back into the into the balance organ on the right side of my head comes up. Um um and that you do have quite a good success rate. I think in the in the region of about 80% or so, there are other options. So that's called the symbols maneuver. I think that's how you say it. Um, again, this is, um, is also treating right, right, ppd? So again, this is these this minute, if it's sometimes done if he, um um the evidence isn't successful with them. Okay? Head goes to the other side of the balance problem and come down to the side. That's probably to the right side and right Canal BPPV on the phone for about a minute, and you just change sides. Sometimes you see him, um, quite aggressive. Similar maneuvers being done. You really see people kind of throwing down one side to the other side. I'm not sure if that has more advantage to develop to the other one. I guess you're creating more force. So, you know, there's more chance of, you know, getting those crystals back into where they should be better. Um and then So that's that's talking about posterior canal BPPV, Um which, as I said, is by far the majority of cases, probably between 16 80% of them off BPPV. Um, yep. But, um, as I said before the, um, if the dictum pike test doesn't, uh, prevent nystagmus will creates the wrong type of nystagmus. You should consider the horizontal cannot BPPV been a typical history. Um, on dumb whilst hysterical. BPPV often predicts symptoms when people are lying down. So patients often report symptoms when they're turning in bed or when they're kind of, you know, stepping their neck up or or bending down with horizontal cannot BPPV Vertigo, which is usually very severe, usually walk upright enough to turning the head. And there's diagnostic test, which I showed a sec. All the supine roll test, Um, and the that test basically test both the horizontal canal. So it's a bit of a difficult test to interpret, which I must admit I would not myself feel confident that I've put a table down there, which just shows how you would interpret. The test is usually, um, based on how intense the nystagmus is, kind of whether it be towards the ground, whether it's geographically or in the opposite direction. So and it gives an idea of whether it's in the and actually in the canal or whether it's a tear into the computer in the horizontal. This is the supine roll test of patient. Um, it's like down turn the head to one side and you just look at it, observe for any mistakes. And then, um so the right hand side and then you just look for a stagnant. So it's It's quite simple test. It's much more simple than the um yeah, please. Okay, Um, right. So if we go to voting around, too on 80 year old woman attended her GP do to recurrent attacks of vertigo, she often experienced the feeling off fullness in her right ear and fluctuating tinnitus, sometimes preceding the vertigo attacks during bouts of vertigo, which was severe and lasted a number of hours for hearing was impaired in the right here after attacks, she felt very tired and slept for many hours. Over the years, the hearing in her right eye had gradually bean declining. Um, Thie, case history. Um okay, so you keep in the polls, okay? I think I could present full screen here. Let's have a lick. All right. Many years, disease, which is the correct answer. So So make sure you got it. Well done. Um oh, yes. Oh, yes. I put on any MRI in there just to try and confuse you feel like that. I mean that that's a normal looking MRI. There's no evidence of any if you still remember in there. Um, so many years. Disease. Um, there's still some confusion as to what does cause it. It's sort of being a fluctuation in the indolent precious within the labyrinth. Um, but there's some question of whether it's an epi phenomenon. I don't get into all that, um, so usually patients present between the age of 30 and, um, later on, because usually you know, around the six decades says usually older patients, um, that's four classic symptoms is fluctuating tinnitus, fluctuating vertigo, fluctuating hearing loss, fluctuating. A little fullness. The average attack lasts 2 to 4 hours. Well, there's a lot of variation there, often much shorter than that even much longer. Um, and following a severe attack, most patients are exhausted and need to sleep for several hours. But I'm not sure how surprising that is. Because what we would take it out of you, Um, and then between the acute attacks, most people are free of symptoms or note mild imbalance and tinnitus. Um, and that could be, you know, it's very variable. You can have mumps, you know, years between attacks. Um, in most cases, especially time goes on, the patients tend to get progressive hearing loss in the affected year on a lot of patients get symptoms affecting. The opposite ear is well, um, and the pattern of hearing loss it Syria kind of low frequency hearing loss. Lower frequencies tend to be worse affected on this quite interesting video. So thean visible hands. It is a cc TV footage. Really? Um, Well, drop attack. Guess he said, which is, um, it is a patient with many as dizzy. Um, So, um, I play that again. So this is this's a reason why many patients with many years get very anxious. And, uh, you know, you suffer a lot of depression and things like that because, um, this is thought to be in a very sudden change in pressure and cause people to really topple over and have this violent falling a very kind of drop attack drop attacks in their own writer there any kind of descriptions. There's lots of different causes. They're usually associate there, and they're often associated with them. Epilepsy. The kind of atomic epilepsy and things about him. Many years. Disease is, um it is a known cause of drop attacks is Well, um, in terms of treatment for many years again, this is kind of, um, certainly exiting my area of expertise. But, um, you can give these kind of the stimulus sedatives, um, things like prochlorperazine be to histamine, which is antihistamine. Um, I think some patients, especially you suffer drop attacks. Um, make it and, uh, they begin them. Use gentamicin to literally can't destroy the vestibular system to him. Um, prevent, um, in a horrible, unpleasant symptoms side up. Um, there's, um, some called vestibular rehabilitation, which is which could be very useful for patients with vestibular problems in general. Um, on days also things like balance, physiotherapy. So, um, the vestibular system has a good it doesn't kind of recover. Well, it's and people adapt Teo problems quite well. And so I'm having that special support to help his. It's very usual for patients, um, and obviously audiology and things like that. If there's, um, hearing aids and things. A lot of patients have anxiety and things, so CBT and relax a shin therapies could be useful. Apparently, there's some evidence that some people advocate in those salt diet of of weeding things like alcohol and caffeine stopping smoking. So that's gonna recommend Italy any chest website about a certain way. My knowledge of many years is quite limited. It tends to be an ent GPC deal with that. So waiting around 3 47 year old patient was admitted to the stroke ward with an attack of vertigo lasting around 24 hours. The new oral article examination was normal, except for a few beats of left beating nystagmus examination was limited by Oh, I closure and severe nausea. There was no associative headache. Uh, MRI with diffusion weighted imaging before the next day. It did not show any evidence of acute stroke. She gave a prior history of it. Least five identical attacks on mentioned a long standing history of migraine with aura. She often experienced a sense of spinning on turning her head too quickly. Six Hallpike and supine roll tests were negative. Is the third case. Um, I even that, um, and presenting full screen. So if ever gets voting on this one every five seconds. Okay, step that migraine, Uh, is the correct answer. Um, BPPV Surprised no one chose it. BPPV because there was said about the, you know, slightly short lived attacks is well, then again, a lot of patients with migraine higher proportion of patient with migraine sufferer, with them BPPV even aged matched. Yeah. Other population moderates visit belies. I'm glad no one shows that one because there's no such thing. And ppd Yeah, it's not about shot, is it? Um Okay, so answer is indeed vestibular migraine on the stimulant migraine is basically eyes it. It's a difficult one. That's a difficult diagnosis. And I always feel that whenever you make it, you never entirely sure. And is this association of them the stable symptoms and migraine symptoms? Um, the presence or or history of brain is essential for a diagnosis, but the headache and the stiffness symptoms, you know, needed temporary coincide tempo really coincide. And that's something which is, I don't think I really realized for a long time. And I always kind of assumed that stick stick with the migraine was, ah, see in a migraine aura, causing some of the stiffness symptoms, after which university headache would follow better. That's really not the case. It it'll I'll show you that for the diagnostic criteria for still a migrant in a second. A set BPV is also common in patients with migraine. Makes things even harder as these things like ppd. So, um, so it could be very difficult pitting down the problem. Um, I'm really being confident in terms of when you, if you want to treat the stipulate migraine, um, the general treatment is exactly the same as any sort of migraine. There's no particular preventive drug which seems to be better for this tablet migrant than any other there. Will this cause he each other From what? You know, the evidence that we have? Um, well, there with the caveat off the, you know, being limited by the availability of the evidence. Um, this is the, um the I see the international head classification of headaches is yours criteria for this time of the migraine. Um, and it's a bit of a bit difficult to work out, but essentially, um okay, um confirmed vestibular migraine. You need to have basically migraine symptoms associated with so some headache, fate a favor and stuff of that associated with the stimulus symptoms at least half the time. So that's kind of stable migraine. However, if you look at the bottom, you see probable this table of migraine, which basically says that you need a diagnosis of migraine in the background on. You need to have had kind of five similar exits. Um, but you don't, um you don't necessarily need to go there to be 50 50% rule on gum. The symptoms aren't better accounted for by another vestibular problem. So it's basically saying you've got migraine and you have these kind of attacks of vertigo which can't find it obvious cause for so so it is quite generic. Um uh, Okay, So this is the last voting round. Um, 25 year old woman presents to the emergency department with a sensation of spinning and nausea with unsteadiness on walking. She was otherwise well, with no relevant past medical history. On examination, her speech sounded a little slurred, and she had a course postural tremor of the right arm. Okay, Right. So I'll give you a bit of time just to vote for that one. Okay. 54, three to one stroke. Migraine isn't interesting. Is a a mix Eso strike was the most common one here. Um, and it's kind of somewhat of an even split between the others with multiple sclerosis gang Course of the weight. Um, say, um um I, um it was a video with it, actually, which actually never showed you as well. This's the video. Um, so we thought we'd have them changed everything for someone, but that's the passage of nystagmus that she had. So the answer in this case is, um, multiple sclerosis. Um, I'm interested. That strike was the most popular choice there because, um, being a young women, um, the multiple sclerosis would probably be more likely and kind of cause of symptoms. I don't think Did I say I didn't really say how quickly the the vertigo came on? Because that would obviously be a very important piece of information, cause obviously, if it did come on instantaneously. Um, uh, Then, um, you might see more strongly suspected stroke or something. Um, the So this nystagmus here, try him through them little segments, Um, which is a pathological or least either congenital or pathological. What you think here. So there's no fast or slow face. The the the stack Ms Pattern hasn't have seen you saw a little of appearance. It's kind of them. It's like a sign wave. There's no rather than being a kind of slow drift in one direction and the fast face back to the other, you're basically just seeing it kind of them, um, unequal, left and right, which is quite even, um, it like a pendulum going back and forth. I guess so. That is, um, the most common acquired cause, if that is multiple sclerosis on the the location of that lesion is, um, usually the central take mental tract, which I've helped me put on on one side. So you can see you on that diagram that you've got the red nucleus in the mid brain. You got the inferior A living in this medullary thing. That's so there. That's the that's connected by the central take mental track. Um, and you've got another PSA connection going to the dentist nucleus. Um, that's better than the triangle that called the moderates triangle, which is, um, kind of use of a new. And you're anatomical. Think, um, so the the case, in her case, the her postural tremor. Would it be a reasonable tremor? Kind of severe, sort of ruble tremor relating to problem around the air of the red nucleus? Um, on da, uh, some patients with them problems in this area Get funny, symptom. Really get a little more clonus is Well, see, I get these kind of funny and, um yes, rhythmic kind of movements of this off pellet. Um, again, these things are rare to see, but again, just think about things in a new Ritalin. You're up on the topical perspective. Um, but, um Yeah, the I guess the case in point with her is that there's, um she had this during the examination. She had neurological signs, which were, um, did you know which you wouldn't necessary, which point to a central cool she's got you mentioned. Her speech is a bit slurred. Um, he's got this tremor a tax. Except she's, um So there seems to be a central problem going on in someone off her age. Multiple sclerosis would be the, um, the most likely diagnosis on with the pendulum nystagmus is there. There can be other causes, and sometimes you see it in them people here, one blind on dental congenital forms of stack. Ms. Um Great. So that's the last case on do the end of the presentation. Um, my main message is is, um, dizziness and the term dizziness is extremely wide ranging with a dizzying range of connotations. Um, on the first step, I think it's just to define exactly what patients mean by dizziness, and even then it can be a minefield. Even this week, I found myself, um, married, trying to understand what So I meant by their symptoms, you know, Laden's of traffic kind of floating above her eyes and so I still have no idea. So I'm trying to understand what people mean. Um, in terms of us neurologists on also better, I think, Importantly, just in the medicine General. Acute medicine. The main question is, does the versus represented peripheral or central? Um, that's okay. Um Andi, there are some clinical clues. As I said, Ah, good neurological examination. Parental nerve exam is very useful. If you see anything abnormal on that, then you start to think about central causes more on the hints exam and pin things down to some extent, especially the head impulse test. However, what the tests are in perfect on be on so many occasions I have seen patients who have had, um, you know, positive head impulse test or they've had that morning that mold vertigo on its own. And you're sure it's gonna be one thing and it turns out to be something else even. Sure, it's gonna be a central cause it in terms of being a protocols and vice versa. So despite the whole presentation, talking about how to difference the differentiate things clinically, um, I think it's actually very difficult on I would save it. If you're in any doubt as to the symptoms, which you probably should be, I'd have a very low threshold for imaging structure. Extremely common on day on. If you miss a stroke, that could be very bad. So s o. You know, I wouldn't worry about kind of safe money. Ah, just, um you know, if there's any doubt that an Emily scam, Um, so that is my presentation. My sister asked approach. Um, I will get back. Teo. Alexa, Teo. Just to see if there are any questions. I think that was there was just one during the presentation. Jimmy, thanks so much. Why? You know, people get tired with many as disease. Yeah. No, I have no idea either. Said I'm hardly an expert in many years. Disease. Um, I will look it up. I'm looking up the thing I can imagine that just a terrible bout of vertigo. I would be a pretty Ah, um, pretty exhausting. And especially if it affects you in your sixties or seventies and stuff. It's, um um probably more likely to get tired, but that's a very terrible answer. So, um, I don't know. I think in terms of, I think just ah, I think the Christian having seen somewhere because like, they really, really recently it's off. If they've had it for a few days, I guess that's sort of you should be confirmed. I'm already shouldn't be if you're suspecting a central core is rather than the CT. Uh, yeah, I should have mentioned this. Actually, I was I'm into some point. So when you Esposito is a terrible for diagnosing posterior circulation strokes, MRI. So you just can't count on a CT. Teo doing is a posterior circulation strike on even MRI's are not infallible. So I think it's about 12% of scans are false negatives. So So people have had strokes, but, you know, the scan doesn't show it at 12% of patients. So even MRI's you know, the best we have, I'm going to waste pick up these strikes. So and certainly I've seen patients who have had, um, you know, a pure form of work to go without any associated a taxi or clinical signs on. Do you do the scan? And sometimes, you know, they would just be a tiny dot tiny diffusion weighted change on the on the scan indicative of a small stroke. Um, so it's very sensitive. Things happen. And strokes also said they're very common and they didn't do slip through. And they said the clinical signs. Yeah, misleading it. Only in the last few weeks, I think, on our consultant walk around the consultant. It is headed post test, and he was sure that someone was gonna have a peripheral vertigo. And later they ended up having a stroke. So, uh, it happens to him, uh, got a couple questions. What are the other differential diagnoses? Which I'm sure it's against be a huge Ah, just vertigo. Uh, yeah. The other differential diagnoses. To be honest, um, for vertigo Specifically, um, I mean, it's mean. It's mainly the ones I mentioned already. Um, as I said, um um, acoustic neuromas and stuff, you know, associated with them 38. But they actually it's quite rare. So if it's typically writers, is which we already talked about them to get, feature is you know, it's quite common cause and causing the court kind of acute vertical symptom without necessary. Any associated signs? Um um but, um, yeah, that that they're really the main ones. that it is one of those things where there isn't a while. It could be quite difficult making the diagnosis. Um, you know, there's not a huge amount things that can cause it. But again, there's a lot of things which can cause, um, vestibular disease. There's a lot of kind of ah triggers for it and things like that. There's a you know, infections that stabilizes things like that. There are drugs. Um, and then if you look at course, especially bilateral vestibular dysfunction. Um, if you look at these kind of pie charts, of course, is a huge number of them is kind of idiopathic. There's a lot of the time it causes and necessarily found. So, um yeah, so no great answer either, Is it? Uh, when How would a stimulus? I'm I'm presenting regarded versus a a stiffness when I'm moving the specialist area of Plymouths research expertise. So sorry I missed it. Did you say that I would have vestibular one? Oh, my present in regards to vertigo? Yeah, that's a very good It's a good question and wonder I am. I was looking up And the fact that matters, I don't think I've I think it's Szmyd to be paroxysm over. So I think, um, but again, it's, um um again, I haven't I can't think of a single a single Vertigo case where they've ended up having a sort of the simplest one over is that they're usually hearing loss. Um, and even because I I read a thing recently, which was, you know, kind of Ah, a specialist balance clinic telling about, you know, the number of patients with vertigo that had bean diagnosed with with acoustic neuroma. And even that was kind of a very small amount is kind of in the region of about, um, you know, is lesson that percent or something like that. So it's, um it's a rare cause, but I think it's I think it's meant to be a kind of paroxysmal vertigo by I'm. I'm sure it could be a kind of more persistent thing and probably a kind of general feeling of unsteadiness and balance. Maybe not necessarily with Frank, Vertigo goes, and maybe a kind of sort of slowly progressive feeling of unsteadiness, maybe with some superimposed attacks of vertigo. That's that would probably be my um, yeah, what it sounds like from my friend. Okay. Uh, is there any questions you have? We'll give it another minute or so and then we will at off. Thank you. Anyone has any other questions? Uh, okay. Uh, I would just continue. I would just continue programming what's coming up then we'll just wait and see if there are any other questions. So yeah, Thanks again for coming. So I brought. We have got our next session is on the cute straight, which helps it will work for anyone. Was, unfortunately the witness me furiously trying to get the technology to work The last time we tried it in March. That was on Monday a p m eso hope. See, they're like, say, everything. Everything is available online. A couple people ask questions. We generally try and upload the slide debts up or meddle with it once, two weeks and then there should be the full sort of video available to watch again, I think on here, but medal as well as on YouTube is Well, if you want to look up, you could still get certificates and stuff if you watch the video. But when he cheap, they're still the option to fill out the feedback V a portfolio for any foundation doctors or anyone else coming up to a RCP know. That sort of thing is incredibly important right now. Uh, for me is is enough. But yeah, there's no there's no questions that come through, So I think we'll say goodbye for now. Thanks again, Jamie. Thank you.