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A clear and different approach to understanding patients with vertigo

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  1. 1. A clinical approach to the diagnosis of vertigo John Waterston Alfred Hospital Melbourne
  2. 2. Traditional neurological diagnosis►Localisation of lesion site “where”►Identification of pathology “what”
  3. 3. HOWEVERThe vast majority of cases of vertigoare due to peripheral causes orbenign central conditions (migraine).
  4. 4. Is it vertigo?► Definition: an illusion of motion  Spinning, dropping, tilting, falling  “something moving inside my head”► Usually aggravated by head movements► Differential diagnosis large  Anxiety and hyperventilation  Postural hypotension
  5. 5. Syndrome approach►Acute, chronic or recurrent►Spontaneous or (head) motion- induced
  6. 6. 4 key syndromes►Acute vestibulopathy►Recurrent vestibulopathy } spontaneous►Motion-induced vertigo►Disequilibrium
  7. 7. 1. Acute vestibulopathy Vestibular neuritis Stroke (PICA, AICA) Perilymph fistula Trauma
  8. 8. Vestibular neuritis (neuronitis)►A common cause of acute vertigo► Many cases thought to be due to reactivation of herpes simplex I► Similar pathogenesis to Bell’s palsy► Acute vertigo, unidirectional nystagmus
  9. 9. Normal VORAbnormal VOR Halmagyi & Curthoys, 1988.
  10. 10. Management:Shupak et al, Otology & Neurotology. 2008. 29:368-374.Strupp et al, NEJM. 2004. 351:354-361.► Prednisolone aids clinical and laboratory recovery  1 mg/kg for 5 days, followed by reducing dose over next 15 days.► Valacyclovirineffective► Other treatment  prochlorperazine, promethazine
  11. 11. HINTS to Diagnose Stroke in the Acute Vestibular SyndromeThree-Step Bedside Oculomotor Examination More Sensitive Than Early MRI Diffusion- Weighted Imaging Jorge C. Kattah, MD; Arun V. Talkad, MD; David Z. Wang, DO; Yu-Hsiang Hsieh, PhD, MS; David E. Newman-Toker, MD, PhD Stroke 2009;40;3504-3510
  12. 12. HINTS (high stroke risk)►Head►Impulse (normal)►Nystagmus (direction changing)►Test of►Skew deviation (present)
  13. 13. Benign HINTS examination result at thebedside “rules out” stroke better than anegative MRI with DWI in the first 24 to48 hours after symptom onsetThe sensitivity of early MRI with DWIfor lateral medullary or pontineinfarction was lower than that of thebedside examination (72% versus100%)
  14. 14. 2. Recurrent vestibulopathy Migraine Meniere’s disease Vertebro-basilar insufficiency Vestibular paroxysmia Focal epilepsy Episodic ataxia
  15. 15. 3. Motion induced vertigo Uncompensated peripheral lesion Benign positional vertigo Migraine Cerebellar disease Cervical vertigo Usually respond to physical treatment modalities
  16. 16. Benign positional vertigo► ~25% of cases of vertigo.► May be primary or secondary.► Short-lived bouts of vertigo.► Positional features  in bed, head extension (“top shelf vertigo”), bending.► Usually curable!
  17. 17. Mechanism of benign positional vertigo
  18. 18. Diagnosis► Must see nystagmus with vertigo► Patients with other vestibular disorders will often feel dizzy during the Hallpike manoeuvre► Spontaneous or central nystagmus may be more prominent during positional testing
  19. 19. Epley manoeuvre (right sided BPV)
  20. 20. Semont manoeuvre for right sided BPV
  21. 21. Brandt-Daroff exercises for management of benignpositional vertigo (posterior canal) Acta Otolaryngol. 1980;106:484-485
  22. 22. 4. Disequilibrium ► CNS  cerebellar disease  normal pressure hydrocephalus  multi infarct state ► Proprioceptive loss  spinal disease  peripheral neuropathy ► Other  bilateral vestibular hypofunction  ageing  hypothyroidism  multi-sensory dizziness/disequilibrium (visual, vestibular, cervical spine, neuropathy, orthopaedic)
  23. 23. “Red Flags” ► Other neurological signs ► Ataxia out of proportion to vertigo ► Nystagmus out of proportion to vertigo ► Central nystagmus  vertical, gaze evoked, dissociated, acquired pendular ► Central eye movement abnormalities  broken pursuit , gaze palsy, dysmetric or slow saccades, skew deviation
  24. 24. Summary► Learn to differentiate between spontaneous and (head) motion induced vertigo► Think of migraine, particularly in the younger patient presenting with unexplained recurrent vertigo.► Vertebro-basilar ischaemia is a rare diagnosis► Examine the eye movements carefully► Do a Hallpike test (except when there is obvious spontaneous nystagmus).