Vertigo

Tunde Magyar MD, PhD

What could be reffered to as dizziness by the patient?

Rotational vertigo Sense of instability Ataxia of gait Disturbance of vision Loss of contact with surroundings Nausea Loss of memory Loss of confidence Epileptic convulsion

Development of vertigo
Afferent
Visual Proprioceptive Vestibular

CNS
Dizziness

Efferent
Oculomotor Sceletal muscles Vegetative

What should be considered dizziness by medical personnel?

1. Vertigo
A sense of feeling the environment moving when it does not. Persists in all positions. Aggravated by head movement. A feeling of unsteadiness or insecurity without rotation. Standing and walking are difficult. Swimming, floating, giddy or swaying sensation in the head or in the room.

2. Dysequilibrium

3. Light headedness

Questions to be asked (taking the history)

1. Anamnesis

What the patient means by vertigo Time of onset Temporal pattern Associated sings and symptoms (tinnitus, hearing loss, headache, double vision, numbness, difficulty of swallowing) Precipitating, aggravating and relieving factors If episodic: sequence of events, activity at onset, aura, severity, amnesia etc.

Examination of the patient with vertigo

2. Physical examination

Spontaneous nystagmus Positional nystagmus Optokinetic nystagmus Posture and balance control
Rombergs test Blind walking, Untenberger Brnys test
Caloric test (cold, warm water) Rotational test

Stimulations of labyrinth

In case of vertigo
No sponteous nystagmus Posture and balance control negative Nausea vomiting Sweating, tachycardia Anxiety Sponteous nystagmus Posture and balance control positive Nausea, vomiting, sweating, anxiety Harmonic vestibular sy Loss of hearing, tinnitus Psychiatry Vestibular neuronitis, Menire disease Otology Dysharmonic vestibular sy Numbness, double vision, dysarthria Brainstem infarct

GI disorder Chest pain Internal medicine Angina, MI

Cardiology

Neurology

Differentiating peripheral and central vestibular lesion

1. Peripheral
harmonic vestibular syndrome Falls in Romberg position and deviates during walking with closed eyes to the side of the slow component of nystagmus Direction of nystagmus does not change with direction of gaze (I. II. III. degree!) Nystagmus can be horizontal, or rotational, but never vertical Nystagmus occurs after a brief latent period Severe rotating, whirling vertigo Symptoms aggravate after moving of the head position Severe vegetative sings (vomiting, sweating) Fear of death in severe cases Caloric response decreased on side of lesion

Differentiating peripheral and central vestibular lesion

2. Central dysharmonicvestibular syndrome (rarely harmonic!!) Falls in Romberg position and deviates during walking with closed eyes to the side of the fast component of nystagmus Direction of nystagmus might change with direction of gaze If nystagmus is vertical or dissociated, it cannot be peripheral Vertigo is usually not whirling Vegetativ signs are less severe if any Associated neurological signs: diplopia, dysarthria, dysphagia, numbness, paresis, ataxia.

Examination of the patient with vertigo

3. Laboratory examinations and imaging
Electronystagmography Video-oculography Audiometry BAEP CT MRI

Common causes of vertigo

1.

Peripheral
Physiological (motion sickness) Benign paroxysmal positional vertigo Vestibular neuronitis Labyrinthitis Menire disease Perilymph fistula

2.

Central
Brainstem TIA/infarct Posterior fossa tumors Multiple sclerosis Syringobulbia Arnold - Chiari deformity Temporal lobe epilepsy Basilar migraine

3.

Other
Cardiac, GI, psycogen, toxins, medications, anemia, hypotension

Duration of vertigo
Time
Seconds

Peripheral
BPPV

Central
VB-TIA, aura of epilepsy

Minutes
(Half) hours Days Weeks, Month

perilymph fistula
Menire disease vestibular neuronitis labyrinthitis acustic neurinoma, drug toxicity

VB-TIA, aura of migraine

basilar migraine VB stroke multiple sclerosis cerebellar degenerations

Peripheral types of vertigo

1. Benign paroxysmal positional vertigo

Most often Lasts less than 30 seconds Occurs only with a change in head position Nystagmus is transient, fatigable and its direction is constant Reason: otoconia

Positional vertigo is not always benign and not always vestibular in origin!

Left AC

Right
AC

HC

HC

PC

PC

BPPV diagnosis: Dix-Hallpike manoeuvre

BPPV: therapy
Medications not necessary Position training

Semont

Brandt-Daroff

2. Vestibular neuronitis
Sudden severe vertigo harmonic vestibular syndrome No cochlear symptoms (tinnitus, hearing loss) Reduced caloric reaction on affected side Recurrent attacks Lasts for several days

2. Vestibular neuronitis
Reason: viral infection, vascular or unknown origin Therapy: 1-3. days. bedrest, vestibular suppressants (diazepam, clonazepam) antiemetics, vitamin B antiviral agents (?), corticosteriods(?) From 3. day: position training

3. Labyrinthitis
As vestibular neuronitis, but there are also cochlear symptoms.

4. Menire disease
Recurrent attacks in clusters Tinnitus Progressive hearing loss, unilateral first Vertigo for at least 5 to 30 min Vegetative signs Sense of pressure in the ear Distorsion of sounds Sensitivity to noises

4. Menire disease
Pathogenesis: endolymphatic hydrops Therapy: salt free diet, nicotin, alcoholwithdrawal, acetazolamide, betahistine

5. Perilymphatic fistula
Fistula of the round window Hearing loss with or without vertigo

Sudden changes of pressure in the middle ear (weight lifting, diving, nose blowing)

Drug toxicity
Aminoglycoside antibiotics Anticonvulsants Salycilates Alcohol Sedatives Antihistamines Antidepressants

Other causes of vertigo

Cervical spondylosis Sensory deprivation (neuropathy, visual impairment) Anemia Hypoglycaemia Orthostatic hypotension Hyperventilation