Vertigo Professor Yasser Metwally

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

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 Efferent Oculomotor Sceletal muscles Vegetative Dizziness

What should be considered dizziness by medical personnel? Vertigo A sense of feeling the environment moving when it does not. Persists in all positions. Aggravated by head movement. Dysequilibrium A feeling of unsteadiness or insecurity without rotation. Standing and walking are difficult. Light headedness Swimming, floating, giddy or swaying sensation in the head or in the room.

Vertigo

A sense of feeling the environment moving when it does not. Persists in all positions. Aggravated by head movement.

Dysequilibrium

A feeling of unsteadiness or insecurity without rotation. Standing and walking are difficult.

Light headedness

Swimming, floating, giddy or swaying sensation in the head or in the room.

Questions to be asked (taking the history) 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.

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 Romberg’s test Blind walking, Untenberger Bárány’s test Stimulations of labyrinth Caloric test (cold, warm water) Rotational test

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

In case of vertigo No sponteous nystagmus Sponteous nystagmus Posture and balance control negative Posture and balance control positive Nausea vomiting Sweating, tachycardia Nausea, vomiting, sweating, anxiety GI disorder Chest pain Anxiety „ Harmonic” vestibular sy „ Dysharmonic” vestibular sy Internal medicine Angina, MI Loss of hearing, tinnitus Numbness, double vision, dysarthria Cardiology Psychiatry Vestibular neuronitis, Meniére disease Brainstem infarct Otology Neurology

Differentiating peripheral and central vestibular lesion 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

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

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. 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.

Examination of the patient with vertigo 3. Laboratory examinations and imaging Electronystagmography Video-oculography Audiometry BAEP CT MRI

3. Laboratory examinations and imaging

Electronystagmography

Video-oculography

Audiometry

BAEP

CT

MRI

Common causes of vertigo Peripheral Physiological (motion sickness) Benign paroxysmal positional vertigo Vestibular neuronitis Labyrinthitis Meniére disease Perilymph fistula Central Brainstem TIA/infarct Posterior fossa tumors Multiple sclerosis Syringobulbia Arnold - Chiari deformity Temporal lobe epilepsy Basilar migraine Other Cardiac, GI, psycogen, toxins, medications, anemia, hypotension

Peripheral

Physiological (motion sickness)

Benign paroxysmal positional vertigo

Vestibular neuronitis

Labyrinthitis

Meniére disease

Perilymph fistula

Central

Brainstem TIA/infarct

Posterior fossa tumors

Multiple sclerosis

Syringobulbia

Arnold - Chiari deformity

Temporal lobe epilepsy

Basilar migraine

Other

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

Duration of vertigo Time Peripheral Central Seconds BPPV VB-TIA, aura of epilepsy Minutes perilymph fistula VB-TIA, aura of migraine (Half) hours Meni é re disease basilar migraine Days vestibular neuronitis labyrinthitis VB stroke Weeks, Month acustic neurinoma, drug toxicity multiple sclerosis cerebellar degenerations

Peripheral types of vertigo 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!

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 Right HC HC AC AC PC PC + -

BPPV diagnosis: Dix-Hallpike manoeuvre

BPPV: therapy Medications not necessary Position training Semont Brandt-Daroff

Medications not necessary

Position training

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

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.

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. Meni è re 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

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. Meni è re disease Pathogenesis: endolymphatic hydrops Therapy: salt free diet, nicotin, alcohol-withdrawal, acetazolamide, betahistine

Pathogenesis: endolymphatic hydrops

Therapy: salt free diet, nicotin, alcohol-withdrawal, 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)

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

Aminoglycoside antibiotics

Anticonvulsants

Salycilates

Alcohol

Sedatives

Antihistamines

Antidepressants

Other causes of vertigo Cervical spondylosis Sensory deprivation (neuropathy, visual impairment) Anemia Hypoglycaemia Orthostatic hypotension Hyperventilation

Cervical spondylosis

Sensory deprivation (neuropathy, visual impairment)

Anemia

Hypoglycaemia

Orthostatic hypotension

Hyperventilation