Neurology USMLE** Flashcards

1
Q

A patient comes to the office for evaluation of headache. What is the most likely diagnosis when a woman with unilateral HA that is throbbing at the time of menses. She is nauseated and sees bright flashing lights. Light hurts her eyes and sounds are painful.

A

Migraine HA. more often unilateral with autonomic problems such as N&V. Visual problems such as bright flashing lights, zigzags of lights, or visual field defects also occur. There may be photophobia and phonophobia. Migraines can be preciptated by menstruation, physical or emotional stress and loss of sleep.

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2
Q

A patient comes to the office for evaluation of headache. What is the most likely diagnosis when bilateral squeezing pain like a belt tied around her head.

A

Tension HA are bilateral and “bandlike.” There are no associated neurological problems.

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3
Q

A patient comes to the office for evaluation of headache. What is the most likely diagnosis when a man with unilateral earing and redness of his eye and nasal stuffiness. There are several short HA.

A

Cluster HA are 10x more common in men. There are multiple short HA in a limited period of time. They are very severe with redness of the eye, lacrimation, rhinorrhea, and nasal stuffiness. Horners syndrome sometimes occurs.

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4
Q

A man comes in with severe facial pain that occured while his wife was gently stroking his face. The pain is extremeley severe, started at one side of his face and is like “a nail being driven into my cheek.” What is the most likely dx, what is the best initial therapy?

A

Trigeminal neuralgia or “tic douloureux” is an idiopathic disorder of the fifth cranial nerve. There is sudden severe pain of the face brought on by touch, chewing or movement. The pain is lancinating and unilateral. Trigeminal neuralgia is treated with carbameazepine. If medical therapy is not effective, surgical resection of the nerve may be necessary.

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5
Q

An elderly man is brought to the ED with sudden onset of weakness over the right side of his body, dysarthria and loss of his right visual field. His head CT is N. What is the most likely dx when the symptoms began with unilateral loss of vision on the L side. All sx resolve in 6 hrs. MRI is N.

A

TIA begins with the loss of sensory and motor dunction that resolves in <24h. All imaging studies are N. TIAs often begin with “amaurosis fugax” which is a transient loss of vision. The visual loss is ont he contraleteral side from the other sensory and motor loss. This is from a carotid embolus on the same side as the visual loss.

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6
Q

An elderly man is brought to the ED with sudden onset of weakness over the right side of his body, dysarthria and loss of his right visual field. His head CT is N. What is the most likely dx when the symptoms persist. MRI of the head is abN in 24h

A

Stroke is a permanent neurologic loss, often from a non hemorrhagic embolic or thrombotic episode of the middle cerebral artery. There is loss of motor and senosry function on the opposite side from the lesion. THis is frequently accompanied by a “homonymous hemianopsia” which is the loss of the optic radiation of fibers through the parietal lobe. A stroke on the left eminates the visual field on the right. patients “look towards the side of the lesion.”

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7
Q

A man presents to the ED with severe vertigo. He is found to have hemifacial anesthesia, dysarthria, dysphagia and sensory loss of his body on the opposite side from the hemifacial anesthesia. He is ataxic and there is a horner’s syndrome present. What is the most likely diagnosis? What is the most accurate diagnostic test?

A

Wallenburg or lateral medullary syndrome is a stroke of the PICA (posterior inferior cerebellar artery). This results in ipsilateral facial sensory loss, contralateral body sensory loss, vertigo, ataxia, dysarthria, dysphagia, and Horner’s syndrome. MRI of the brain is the most accurate way to assess the cerebellum and brain stem. CT scanning does not effectively look at the posterior fossa or the brain stem.

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8
Q

A patient comes in with sudden onset of weakness. The weakness is unilateral and is worse in the lower extremity compared to the arm. Sensory loss is also present that is worse in the leg. He is confused and there is urinary incontinence. What is the most likely dx? what is the most accurate diagnostic test?

A

Anterior cerebellar artery stroke presents with unilateral loss of motor and sensory function. These symptoms are worse in the lower extremity compared to the upper extremity. There is also confusion and urinary incontinence. MRI of the brain is the most accurate method of determining the presence of a stroke. Echocardiography and carotid doppler studies are used to determine the etiology of the origin of the stroke, specifically looking for evidence of vegetations or intracardiac thrombus

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9
Q

A man comes to the ED with sudden, extremely severe HA. This is the first such episode he has ever had. What is the most likely diagnosis when there is photophobia, neck stiffness, fever, and a loss of consciousness from which he recovers?

A

SAH results in a sudden severe HA with meningeal signs such as nuchal rigidity, fever, and photophobia. The two key features are the sudden onset of sx and a loss of consciousness in abotu 50% of patients. CT scan without contrast is 95% sensitive in detection of SAH. LP will detect the rest, showing RBCs and/or Xanthochromia.

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10
Q

A man comes to the ED with sudden, extremely severe HA. This is the first such episode he has ever had. What is the most likely diagnosis when he has unilateral loss of vision which persists

A

Temporal Arteritis leads to severe unilateral HA associated with loss of vision as well as tenderness of the scalp and the artery. The answer is always to giver steroids rather than wait for a temporal artery biopsy. There may be jaw claudication and onset is in the elderly.

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11
Q

A woman comes in because of severe back pain. What is the most likely diagnosis when there is a history of cancer, spine tenderness, hyperreflexia, urinary incontinence, and loss of sensation in the lower extremities?

A

Spinal cord compression from metastatic disease is thoguht to be present when back pain is accompanied by tenderness, hyperreflexia, sensory loss below the level of the compression, and sometimes urinary or fecal incontinence. Steroids are critical to prevent worsening.

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12
Q

A woman comes in because of severe back pain. What is the most likely diagnosis when there is no tenderness or facal neuro abnormalities.

A

Low back pain or lumbosacral strain has no accompanying focal neuro probelms. The straight leg raise may elicit pain suggesting disc herniation. This does not change the answer for initial management, which is to give analgesics and not perform routine imaging testing. Do not advise bedrest.

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13
Q

A woman comes in because of severe back pain. What is the most likely diagnosis when there is spinal tenderness, leukocytosis and fever?

A

Spinal epidural abscess is the answer when there is fever, leukocytosis, and spinal tenderness. Imaging such as an MRI should be performed if there is spinal tenderness which suggests a compressive mass.

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14
Q

A child is brought for evaluation of mental subnormality and seizures. What is the most likely diagnosis when there is a port wine stain on the face and leptomeningeal angiomas.

A

Sturge Weber syndrome presents with seizures and mental subnormality in association with a port wine stain and leptomeningeal angiomas.

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15
Q

A child is brought for evaluation of mental subnormality and seizures. What is the most likely diagnosis when facial adenoma sebaceum, renal lesions, and “shagreen patches” are present which are leathery plaques of subepidural fibrosis, usually situated on the trunk. Retinal hamartomas are present. Pale, hypopigemnted “ash leaf” pathces are present.

A

Tuberous sclerosis gives hamartomas of the retina in association with ash leaf hypopigmented areas. There are also lesions of the heart and kidneys. Adenomas sebaceum is redenned nodules on the face. Shagreen patches are also present which are leathery plaques of subepidermal fibrosis, usually on the trunk.

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16
Q

A patient comes in with loss of pain and temperature sensation of the lower extremities. What is the most likely diagnosis when the loss of pain and temperature is bilateral. There is also loss of bilateral motor function. There is striking sparing of position and vibratory sensation bilaterally.

A

Anterior spinal artery infarction results in the bilateral loss of all pain, temperature and motor function below the level of the infarction. There is striking preservation of position and vibratory sensation, which has another vascular supply on the posterior portion of the spinal cord.

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17
Q

A patient comes in with loss of pain and temperature sensation of the lower extremities. What is the most likely diagnosis when a knife wound is sustained to the back. The loss of pain and temperature is on the opposite side of the injury. THere is loss of position and vibratory sense on the same side of the injury.

A

Brown Sequard syndrome is hemisection of the spinal cord. Pain and temperature are lost on the opposite side from the lesion. Position and sense are lost on the same side as the injury.

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18
Q

A patient comes in some time after being involved in a motor vehicle accident. There was spine trauma. The patient has lost pain and temperature sensation in a “capelike” distribution across the neck and down both arms. Touch, position and vibratory sense are intact. Over time there is motoe loss below the level of the injury. What is the most likely diagnosis, what is the most accurate diagnostic test, what is the therapy?

A

Syringomelia presents with loss of pain and temperature in a capelike distribution across the neck and arms. There is sparing of tactile sensation, position and vibratory sense. Reflexes are los. There may be lower motor neuron manifestations at the level of the lesion with upper motor neuron signs below the lesion as the lesion enlarges. Syringomelia is caused by tumours and trauma. MRI is the most accurate diagnostic tests. Surgery is treatment.

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19
Q

An obese young woman comes in for evaluation of a severe HA and double vision. She has recently started OCPs. On physical exam, she has sixth cranial nerve palsy and papilledema. Head CT is N. What is the most likely dx? what is the msot accurate dx? what is the best initial therapy?

A

Pseudotumour cerebri is an idiopathic increase in ICP that occurs more often in obese women who are using OCPs or tetracycline abx. The key to the answer is teh presence of a HA in association with diploplia, papilledema, sixth nerve palsy and a normal head CT. LP is the most accurate dx test. Tx is with the loss of weight, combined with acetazolamide and diuretics. Steroids and surgical shunting are somtimes necessary.

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20
Q

Your patient comes in with multiple bruises on her legs. She is accompanied by her husband, whom she insists is kicking her every night. He denies this. He does say his legs are uncomfortable at night and that this discomfort is relieved by moving his leds. His legs feel “creepy and crawly.” He tries to avoid the problem by staying awake with coffe but this hasnt helped. What is the most likely diagnosis? What is the most effective therapy?

A

Restless leg syndrome is an idiopathic disorder of discomfort in the legs at night that is relieved only by movement. It is worsened by sleeplessness adn caffeine use. The patient describes the sensation as “creepy and crawly” in the leds. The bd partner often brings the patient in becasue of being kicked at night. There is no specific test to confirm the diagnosis. Dopamine agonists such as ropinirole and pramipexole are the treatment of choice.

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21
Q

A man comes to the office for progressive muscular weakness. The weakness is diffuse and is accompanied by dysarthria and difficulty chewing and handling saliva, with a decreased gag reflex. There is spasticity, hyperreflexia, muscle wasting and fasiculations. What is the most likely diagnosis? What is the most common cause of death?

A

Amyotrophic lateral sclerosis (ALS) is the only disease to combine both upper and lower motor neuron dysfunction. Patients come with progressive motor weakness, dysarthria, dysphagia, loss of gag reflex and difficulty handling oral secretions. Only the motor system is affected. Upper motor findings are spasticity and hyperreflexia. Lower motor findings are wasting and fasiculations. Mental function remains completely intact.

22
Q

A man comes to the ED with a seizure. His head CT shows a “ring” or contrast enhancing lesion. There is surrounding edema and modest mass effect. What is the msot likely diagnosis when the patient is HIV negative.

A

Ring or contrast enhancing lesions can be either neoplastic disease or infection. In an HIV negative patient, a brain biopsy must be performed to confirm the diagnosis. There is no clear way to determine a precise histologic type without a biopsy.

23
Q

A man comes to the ED with a seizure. His head CT shows a “ring” or contrast enhancing lesion. There is surrounding edema and modest mass effect. What is the msot likely diagnosis when HIV positive patient. CD4 count is <100. The repeat CT shows a smaller leesion after two weeks of pyrimethoamine and sufadiazine.

A

Toxoplasmosis (intracerebral) occurs in HIV positive patients with <100 CD4 cells. Presents as a ring or contrast enhancing lesion. The response to treatment with pyrimethamine and sulfadiazine for two weeks is sufficiently specific to confirm diagnosis.

24
Q

A man comes to the ED with a seizure. His head CT shows a “ring” or contrast enhancing lesion. There is surrounding edema and modest mass effect. What is the msot likely diagnosis when HIV positive patient. CD4 count is <100. The repeat CT shows lesion is unchanged after two weeks of pyrumethamine and sulfadiazine.

A

Lymphoma presents as a contrast enhancing lesion in HIV positive patients with <100 CD4 cells. There will be no response to therapy for toxoplasmosis. A brain biopsy should be performed to confirm diagnosis.

25
Q

A man comes to the office for evaluation of a tremor. What is the most likely diagnosis in when the tremor is in the hands and occurs at both rest and when he is moving them. It is worse with caffeine. An alcoholic drink improves it.

A

Benign essential tremor occurs both at rest and when reaching for objects. Caffeine and beta agonists make it worse. Alcohol improves the tremor. Treatment is with propranolol.

26
Q

A man comes to the office for evaluation of a tremor. What is the most likely diagnosis in when he is an older patient. The tremor is only at rest and does not occur when he is reaching for an object.

A

Parkinsonian tremor occurs at rest and is not present on intention, such as when reaching for objects.

27
Q

A man comes to the office for evaluation of a tremor. What is the most likely diagnosis in when there is no tremor at rest. When he reaches for something, his hand wobbles considerably.

A

Cerebellar disorders such as stroke result in a tremor only when reaching for things. This is similar to an abnormal finger to nose test. There is no tremor at rest.

28
Q

A man is being evaluated for dementia. He has poor short term memory. What is the most likely diagnosis when he has parkinsonian features such as tremor, rigidity, and gait abnormalities in addition to dementia.

A

Lewy body dementia is accompanied by features of movement disorder of parkinsons disease (tremor, rigidity, gait abnormalities).

29
Q

A man is being evaluated for dementia. He has poor short term memory. What is the most likely diagnosis when the dementia has been rapidly progressive ocer severeal months. He has myoclonus.

A

Creutzfeldt Jakob disease is characterized by rapidly progressive dementia and myoclonic jerks.

30
Q

A man is being evaluated for dementia. He has poor short term memory. What is the most likely diagnosis when there is gait ataxia and urinary incontinence.

A

Normal pressure hydrocephalus is the triad of dementia, gait ataxia and urinary incontinence.

31
Q

A man is being evaluated for dementia. He has poor short term memory. What is the most likely diagnosis when social inappropriateness and emotional lability preceded the loss of memory.

A

Fronto temporal lobe dementia or Picks disease starts with abnormalities of social inappropriateness and emotional lability prior to the loss of memory. There is inappropriate anger, laughing, or crying. MRI of the brain show focal “lobar” atrophy of the brain. Alzheimers disease is slowly progressive loss of memory with no focal neuro abnormalities.

32
Q

A man in his thirties is brought in by his family for cognitive abnormalities. He has developed progressively worsening emotional outbursts such as anger, depression and paranoia. There is a profound movement disorder similar to chorea. He is now showing memory loss. What is the most likely diagnosis? What is the most accurate diagnostic test? What treatment is there?

A

Huntingtons disease consists of personality changes such as emotional instability, paranioa, and depression combined with a movement disorder and dementia. The disease is autosomal dominant. The diagnostic test is for a specific DNA sequence abnormality consisting of CAG trinucleotide repeat sequences. There is no specific therapy.

33
Q

A man is brought to the ED for weakness. The weakness began in his feetand has progressed to bilateral severe weakness in both leds. Knee jerk and ankle reflexes are absent. He recently had an episode of gastroenteritis. What is the most likely diagnosis? what is the most accurate test? what is the treatment there?

A

Guillian barre syndrome consists of ascending weakness that progresses from the feet upward. The weakness may involve the diaphragm, at which time respiratory failure develops. DTR are lost in an ascending fashion. There is an association of Guillian barre after an episode of campylobacter gastroenteritis. The diagnosis is made by nerve conduction studies which show a decrease in conduction velocity. CSF shows an elevated protein with no cells. Pulmonary function tests are crucial to determine who is likely to develop resp paralysis. Treatment is with IVIG or plasmapharesis.

34
Q

An alcholic man is brought to the ED with confusion, confabulation, and agitation. On exam, there is paralysis of the EOM and gait ataxia. What is the most likely diagnosis. What is the best initial therapy?

A

Wernickes encephalopathy is characterized by the development of confusion, gaze palsies, and nystagmus, as well as ataxia of the gait. It is most commonly found in alcoholic patients. It is caused by a deficiency in thiamine that is most commonly seen in alcoholics. Tx is thiamine, there are no specific diagnostic tests.

35
Q

A 72 yo man is evaluated in the office for rigidity, tremor, micrographia, and hypomimia. What is the most likely diagnosis when orthostatic hypotension is the most common significant abnormality.

A

Shy drager syndrome; Parkinsons disease with ortho static hypotension as the main finding.

36
Q

A 72 yo man is evaluated in the office for rigidity, tremor, micrographia, and hypomimia. What is the most likely diagnosis when vertical gaze palsy is striking.

A

Suprenuclear palsy; vertical gaze palsy is the most important feature.

37
Q

A 72 yo man is evaluated in the office for rigidity, tremor, micrographia, and hypomimia. What is the most likely diagnosis when ataxia such as abnormal heel to shin and finger to nose test is the chief complaint.

A

Olivopontocerebellar atrophy; Ataxia is the main feature.

38
Q

A man with metastatic prostate cancer comes in for evaluation of pain and motor weakness of the lower extremities. THere is bilateral leg weakness and sensory neuropathy. “Saddle anesthesia” or loss of sensation in the perianal area is striking. Bowel and bladder abnormalities are present. What is the most likely diagnosis? What is the most accurate diagnostic test?

A

Cauda equina sompression is a peripheral nerve injury that presents with urinary retention, saddle anesthesia, and progressive led weakness. Saddle anesthesia is numbness in the perineum, genitals, buttocks and upper thighs. Urinary retention with overflow incontinence may occur. Anal sphincter tone is decreased in 60 -80% of patients. MRI is the most accurate diagnostic test. Surgical resection of the compressive lesion should occur as soon as possible.

39
Q

A chronic smoker comes in with an abnormal XR with a lesion in the superior sulcus. On physical exam he has dropping of his eyelid on one side. The pupils are unequal in size (aniscoria). The pupil remains constricted in dark light. He does not sweat on one side of his face. What is the most likely diagnosis? What is the most common cause?

A

Horners syndrome is the unilateral presence of ptosis, or a “droopy” eyelid with diminshed elevation combined with aniscoria from the inability to dilate the pupil; as well as anhydrosis, which is the loss of the ability to sweat on one side. Horners is the combination of ptosis, miosis and anhydrosis. Horners syndrome is loss of sympathetic stimulation. This can be congential or from cervical adenopathy, from carotid dissection or from a “pancoast” or superior sulcus tumour.

40
Q

A patient comes in with weakness of the legs progressive over several months. There is loss of bladder control and abnormalities of the DTR. Hyperintense lesions of the white matter of the spine are seen on MRI. What is the most likely diagnosis when the patient is from the caribbean. Motor defects are limited to the legs. There are antibodies to HTLV-1 in the serum.

A

Tropical Spastic Paresis (TSP) is from an unclear effect of HTLV1 on the white matter of the thoracic spine. Defects of the motor and sensory system are limited to the legs. Urinary abnormalities are present as well. There is no proven treatment. Resolution does not occur and the condition is chronic and progressive. THere are no ocular abnormalities in TSP.

41
Q

A patient comes in with weakness of the legs progressive over several months. There is loss of bladder control and abnormalities of the DTR. Hyperintense lesions of the white matter of the spine are seen on MRI. What is the most likely diagnosis when motor defects are present in the arms as well. She had an episode of optic neuritis last year. MRI of the brain shows lesions as well.

A

Multiple sclerosis presents with multiple motor, sensory, urinary and autonomic abnormalities of the entire CNS. Defects tend to relapse and recur. They occur in different areas over time. THe most common single abnormalitiy is optic neuritis.

42
Q

A man comes in with muscular weakness. The weakness makes it difficult for him to chew his food and he has difficulty swallowing. What is the most likely diagnosis when the weakness is worse at the end of the day. Repetitive exerise makes it worse.

A

Myasthenia gravis presents with worsening weakness with repetitive exercise. There is ptosis and difficulty swallowing. The best initial test is antibodies to acetylcholine receptors. The most accurate test is an electromyogram. Tensilon (edrophonium) test confirms the diagnosis.

43
Q

A man comes in with muscular weakness. The weakness makes it difficult for him to chew his food and he has difficulty swallowing. What is the most likely diagnosis when he has a history of lung cancer and repetitive exercise makes it better.

A

Eaton lambert syndrome is a myasthenia like syndrome in associated with small cell lung ca. Repetitive exercise makes it better.

44
Q

A man comes in with muscular weakness. The weakness makes it difficult for him to chew his food and he has difficulty swallowing. What is the most likely diagnosis when the weakness occurred only after an infusion of gentamicin.

A

Aminoglycoside use can provoke muscle weakness by inhibiting the neuromuscular junction.

45
Q

An HIV positive man with 25 CD4 cells comes in for evaluation of multiple motor, sensory and cognitive defects. MRI reveals white matter lesions in multiple places. The lesions do not enhance with contrast. There is no mass effect and no surrounding edema. What is the most likely diagnosis? What is the most effective treatment?

A

Progressive multifocal leukoencephalopathy (PML) results in multiple white matter lesions with no ring enhancement and no mass effect. PML is a viral infection that causes disease only for those with the most profound immunosuppression, such as AIDS with CD4 cells under 50. Toxoplasmosis and lymphoma both give mass effect and contrast enhancement. PML is from the polyoma virus known as the JC virus. There is no specific antiviral therapy known to be effective for the JC virus causing PML. The lesion will resolve if antiretroviral therapy is used that raises the CD4 count.

46
Q

A man comes the the ED because of a sensation of the room spinning around him, as well as nausea. Nystagmus is present on exam. What is the most likely diagnosis when changes in position of his head precipitate the vertigo. Hearing is N and there is no tinnitus or ataxia.

A

Benign positional vertigo is isolated vertigo brough on by changes in the position of the head. There are no other findings.

47
Q

A man comes the the ED because of a sensation of the room spinning around him, as well as nausea. Nystagmus is present on exam. What is the most likely diagnosis when Hearing loss, tinnitus and ataxia are present.

A

Acoustic neuroma or VIII cranial nerve tumour can have prominent ataxia in addition to hearing loss and tinnitus.

48
Q

A man comes the the ED because of a sensation of the room spinning around him, as well as nausea. Nystagmus is present on exam. What is the most likely diagnosis when hearing loss and tinnitus are present. This is the first episode.

A

Labyrinthitis is a viral infection of the inner ear that leads to a single episode of hearing loss, tinnitus and vertigo.

49
Q

A man comes the the ED because of a sensation of the room spinning around him, as well as nausea. Nystagmus is present on exam. What is the most likely diagnosis when there are multiple episodes of hearing loss and tinnitus in addition to a sense of fullness in his ears.

A

Menieres diesase presents with recurrent and persistent episodes of hearing loss, tinnitus and vertigo. This is like persistent or recurrent labyrinthitis.

50
Q

A man comes the the ED because of a sensation of the room spinning around him, as well as nausea. Nystagmus is present on exam. What is the most likely diagnosis when there has been recent head trauma.

A

Perilymph fistula occurs from head trauma resulting in anatomic damage to the inner ear. All forms of vertigo are associated with nystagmus.