Neurological lectures...Vertigo


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Neurological lectures...Vertigo

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Neurological lectures...Vertigo

  1. 1. Vertigo Professor Yasser Metwally
  2. 2. 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
  3. 3. Development of vertigo Afferent Visual Proprioceptive Vestibular CNS Efferent Oculomotor Dizziness Sceletal muscles Vegetative
  4. 4. 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. 2. Dysequilibrium • A feeling of unsteadiness or insecurity without rotation. Standing and walking are difficult. 3. Light headedness • Swimming, floating, giddy or swaying sensation in the head or in the room.
  5. 5. 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.
  6. 6. Examination of the patient with vertigo 2. Physical examination • Spontaneous nystagmus • Positional nystagmus • Optokinetic nystagmus • Posture and balance control • Romberg’s test • Blind walking, Untenberger • Bárány’s test • Stimulations of labyrinth • Caloric test (cold, warm water) • Rotational test
  7. 7. In case of vertigo No sponteous nystagmus Sponteous nystagmus Posture and balance control negative Posture and balance control positive Nausea Sweating, tachycardia Nausea, vomiting, sweating, anxiety vomiting GI disorder Chest pain Anxiety „Harmonic” „Dysharmonic” vestibular sy vestibular sy Internal Angina, MI Loss of hearing, Numbness, medicine tinnitus double vision, dysarthria Cardiology Psychiatry Vestibular Brainstem infarct neuronitis, Meniére disease Otology Neurology
  8. 8. 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
  9. 9. Differentiating peripheral and central vestibular lesion 2. Central • „dysharmonic”vestibular 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.
  10. 10. Examination of the patient with vertigo 3. Laboratory examinations and imaging • Electronystagmography • Video-oculography • Audiometry • BAEP • CT • MRI
  11. 11. Common causes of vertigo 1. Peripheral • Physiological (motion sickness) • Benign paroxysmal positional vertigo • Vestibular neuronitis • Labyrinthitis • Meniére 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
  12. 12. Duration of vertigo Time Peripheral Central Seconds BPPV VB-TIA, aura of epilepsy Minutes perilymph fistula VB-TIA, aura of migraine (Half) hours Meniére disease basilar migraine Days vestibular neuronitis VB stroke labyrinthitis Weeks, Month acustic neurinoma, multiple sclerosis drug toxicity cerebellar degenerations
  13. 13. 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!
  14. 14. Left Right - AC AC HC HC PC PC +
  15. 15. BPPV diagnosis: Dix-Hallpike manoeuvre
  16. 16. BPPV: therapy • Medications not necessary • Position training Semont Brandt-Daroff
  17. 17. 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
  18. 18. 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.
  19. 19. 4. Menière 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
  20. 20. 4. Menière disease • Pathogenesis: endolymphatic hydrops • Therapy: salt free diet, nicotin, alcohol- withdrawal, acetazolamide, betahistine
  21. 21. 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)
  22. 22. Drug toxicity • Aminoglycoside antibiotics • Anticonvulsants • Salycilates • Alcohol • Sedatives • Antihistamines • Antidepressants
  23. 23. Other causes of vertigo • Cervical spondylosis • Sensory deprivation (neuropathy, visual impairment) • Anemia • Hypoglycaemia • Orthostatic hypotension • Hyperventilation