VERTIGO IN NEUROLOGICAL DISORDERS

FREDDY SITORUS
Neuro-otology & Neuro-ophtalmology
Subdivision
Department of Neurology FMUI/ RSCM

DEFINITION OF VERTIGO

An illusion where someone feels his body is moving to the

environment or the environment is moving to him

PHYSIOANATOMY OF THE BALANCE SYSTEM

PERCEPTION

CEREBRAL CORTEX

INTEGRATION

BRAIN STEM

NERVES (Cranial nerve VIII, CN II

Spinovestibulospinal nerves)

RECESSION

RECEPTOR

BALANCE

VISUAL
SYSTEM

VESTIBULAR
SYSTEM

PROPRIOSEPTIVE
SYSTEM

Balance Function and Dysfunction

Interaction of Vestibular, Visual and Proprioceptive systems

Inner ear
(vestibular
system)

Skin pressure
receptors

Ey
e

Central Nervous system

Controls eye
movements

Postural control
via muscles

Balance
dyfunction

dizziness
Goebel JA. Otolaryngol Clin North Am 2000;33:48393.
Shepard NT, Solomon D. Otolaryngol Clin North Am
2000;33:45569

Muscle and
joint
sensory
receptors

Internal Ear
1. bony labyrinth
a. 3 semicircular canals
(1) frontal
(2) horizontal
(3) sagittal
b. vestibule
c. cochlea
________________
perilymph

Pathways

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Types of DIZZINESS
Type
System
Vertigo
Vestibular Vertigo
Vestibular
- Central
- Peripheral
Nonvestibular Vertigo
Visual

Sensation

Spinning

Light headed

Proprioceptive
Presyncope
Cardiovascular

Fainting

History of dizzy patient

History is the most important for
evaluation because:
Dizziness represent many
different overlapping sensation
Different pathophysiological
mechanism many patients
complaining of dizziness dont have
disorders of vestibular system

Identify: Type of Vertigo

VERTIGO
Type :

Vestibular

Site of Lesion :
Vestibular

Non Vestibular
Sistem
Sistem
Visual/Somatosensori

Peripheral
Central
- Labirinth
- Brainstem
- N. vestibularis
- Cortex

CLINICAL DIFFERENCES BETWEEN VESTIBULAR AND

NON VESTIBULAR VERTIGO

SYMPTOMS
Character
Attacks
Nausea/ vomits
Hearing impairment
Provoking movement
Provoking situation

VESTIBULAR
VERTIGO

NON VESTIBULAR
VERTIGO

Spinning sensation

Dizziness,
unsteadiness

Episodic

Continuous

(+)
(+)/(-)
Head movement
(-)

Crowded, traffic jam

Central vs Peripheral
Vertigo

LOCALIZATION OF NEUROLOGICAL DISORDERS :

1. CN. VIII (VESTIBULAR NERVE)..............PERIPHERAL

2. VESTIBULAR NUCLEUS BRAIN STEM
3. CEREBELLUM
4. BRAIN
CENTRAL

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Vertigo can be of central or

peripheral origin
Central

Peripheral

Involving structures in
the central nervous
system
(e.g., cerebrum,
cerebellum,
brainstem)

Involving structures
not part of the central
nervous system, most
frequently the inner
ear

Baloh RW. Lancet 1998;352:18416. Mukherjee A et al. JAPI 2003;51:1095-101. Puri V, Jones E. J Ky Med Assoc
2001;99:31621. Salvinelli F et al. Clin Ter 2003;154:3418. Strupp M, Arbusow V, Curr Opin Neurol 2001;14:1120.

CAUSES OF VERTIGO IN NEUROLOGY

1. CN. VIII (Vestibular nerve)

ie.: infection, tumor, trauma
2. Vestibular nucleus brain stem
ie.: TIA/vertebrobasilar stroke, tumor, infection, trauma,
multiple sclerosis, basilar migraine
3. Brain
ie.: epilepsy, stroke
4. Cerebellum
ie.: stroke, tumor

5. Non vestibular vertigo: refractive disorder, neuropathy, myelopa

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CONCLUSION :
Vertigo determine the type, location, & etiology
Vertigo needs careful history taking & physical examination
Therapy: causative, symptomatic, vestibular exercise

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OPTIC NERVE DISORDER IN

INTRACEREBRAL DISEASE
FREDDY SITORUS

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The Visual Process

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CONVERGENCE
When areas of the occipital cortex detect a
discrepancy in the retinal projection from
each eye and amount of blur, a signal is
sent to initiate convergence.
To bring a near object into focus actually
involves convergence, accomodation (lens
curvature increases) and pupillary
constriction. Together, these 3 movements
are called the near triad.

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CONVERGENCY &
ACCOMMODATION

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Accomodation

1. biconvex lens
2. point of intersection
3. near object = more
convex
4. far object = less
convex
5. role of ciliary
muscle

PUPILLARY REFLEX
PATHWAY

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Examination :
1.Visual acuity
2.Color
3.Visual field
4.Occular movement occulomotor muscles
5.Funduscopy

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VISUAL ACUITY: SNELLEN CHART COLOR VISION: ISHIHARA

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VISUAL FIELD: CONFRONTATION TEST

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VISUAL FIELD: CAMPIMETRY

VISUAL FIELD: AMSLER GRID

VISUAL FIELD: PERIMETRY

(TANGENT BJERRUM)

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VISUAL FIELD DEFECT

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OCCULOMOTOR
TESTING

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FUNDUSCOPY

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FUNDUSCOPY
Hypertensive fundus
Hypertensive retinopathy
Diabetic retinopathy
primary
Papil atrophy
secondary
etc
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HYPERTENSIVE FUNDUS

DIABETIC RETINOPATHY
(PROLIFERATIVE)

HYPERTENSIVE RETINOPATHY

PAPIL ATROPHY
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Etiology
Acute

: Acute infection, trauma, vascular

Chronic : - Chronic infection

primary
- Malignancy
secondary
- Degenerative
- Autoimmune
- Congenital
Therapy : - Depends on etiology
emergency

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Thank you

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Vestibulocerebellar and vestibulospinal pathways and

connections between vestibular and ocular motor nuclei