vertigo for generalists

1. Dr. Srirama Anjaneyulu
MD DM(Neuro)

2. INTRODUCTION
 Dizziness or vertigo
 Diverse etiology but similar presentation.
 Benign to life threatening
 2.5 % of primary care visits.

3. Causes of dizziness

4. Main Categories of Dizziness

5. TYPES
 OTOLOGIC-BPPV , VN , MD, Bil.vestibulopathy,
SCD,PLF,VIII th nerve tumors
 CENTRAL-Migraine ,stroke /TIA , seizures , MS ,
Chiari malformation ,? cervical vertigo
 MEDICAL-Postural hypotension ,arrhythmia , cardiac,
hypoglycemia , drugs, viral syndromes
 UNLOCALIZED-Anxiety ,post traumatic vertigo,
hyperventilation , malingering

6. EVALUATION
 HISTORY
 Define symptom
 Timing
 Triggers
 Otologic history
 Drug history
 Family history
 Review systems
 Previous studies

7. EVAL-PE
 General
 Balance
 Otologic exam
 Neurologic exam
 Nystagmus-spontaneous,Dix –Hallpike ,head shake
test,neck vibration test,valsalva test,hyperventilation
test
 VOR gain

8. dotted lines represent the planes containing the posterior semicircular canal (PSC) of the rightl abyrinth, the
superior and inferior recti of the left eye, and the superior and inferior oblique muscles of the right eye. This
corresponds to the main neuro anatomical connections of the vestibular ocular reflex . Activation of the PSC,
therefore, results in a mixed vertical and torsional nystagmus, with the contralateral eye having more upbeat, and
the ipsilateral eye more extorsional components.

9. Direction, latency, and duration of observed nystagmus

10. INVESTIGATIONS
 Audiogram
 MRI brain
 CT temporal bone
 EEG

11. Finding Peripheral Central
Latency Yes, typically 3-10 sec, rarely as long as 40 sec No
Fatigability* (habituation) Yes, individual episode typically lasts 10-30
sec, rarely as long as 1 min
No
Adaptability* (fatigability) Yes, maneuver done several times
consecutively provokes less of a response each
time
No
Nystagmus direction Direction fixed, typically mixed rotational
upbeating with small horizontal component;
quick phase of intorsion movement toward
the dependent ear, upbeat toward forehead
Direction changing, variable, often purely
vertical (either upbeating or downbeating) or
purely horizontal
Suppression of nystagmus by visual fixation Yes No
Severity Severe, marked vertigo, intense nystagmus,
nausea
Mild vertigo, less obvious nystagmus,
inconspicuous nausea
Consistency (reproducibility Less consistent More consistent
Past pointing In direction of nystagmus slow phase May be in direction of fast phase

12. MIGRAINE -VERTIGO

13. Based on symptom complex
 Bed spins and positional symptoms-
BPPV,central,vestibular neuritis,postural hypotension
 Headache and vertigo-Migraine,post traumatic
vertigo,chiari malformation
 Hydrops-Meniers’s ,perilymphatic fistula,pot
traumatic hydrops,syphilis
 Pressure sensitivity-SCD,PLF,MD,CVJ,stapes
malformation

14. Based on timing
 1-3 sec-VN irritation , MD variants , BPPV variants ,
epilepsy.
 < 1 minute-BPPV , cardiac arrhythmia
 Minutes to hours-TIA, MD, panic attacks ,
arrhythmia
 Hours to days-MD ,migraine
 Weeks or more-vestibular neuritis,central vertigo
with fixed structural lesion, anxiety , malingering ,
bilateral vestibular paresis ,multi sensory
disequilibrium ,drugs.

15. Approach to the Patient with Dizziness

18. Management
 Treat cause
 Explain and assure
 Rehabilitation
 Drugs
 Surgery

19. Drugs

20. MANAGEMENT OF COMMON DISEASES

21. In general the 7 most common
mistakes
 1.Distinguishing vertigo from imbalance;
 2.knowing how to do a positional test;
 3.knowing how to do ahead impulse test;
 4.Migraine is a frequent cause of vertigo without headache
 5.Able to interpret an audiogram;
 6.Arranging to review the patientduring a vertigo attack;
 7. Ordering a magnetic resonanceimaging (MRI) instead of
examining the patient properly.

22. SUMMARY
In the patient with repeated attacks of isolated vertigo
 (1) Always do a positional test.
 (2) Learn to do the particle repositioning manoeuvre.
 (3) Always order an audiogram.
 (4) Try migraine treatment.
 (5) Put vertebrobasilar insufficiency at the bottom of the list.
In the patient having the first ever attack of acute spontaneous
 (1) Learn to do the head-impulse test.
 (2) Always think of cerebellar infarction.
In the patient who is off-balance
 (1) Think of vestibulotoxicity.
 (2) Think of normal pressure hydrocephalus.
 (3) Beware of the posterior fossa tumour or malformation.
 (4) Think of orthostatic tremor.
 (5) Consider spinal cord or peripheral nerve pathology and do a serum B12.

23. Q & A
1. A patient presents with vertigo, diplopia, dysarthria,
weakness and numbness. Which of the following is
the most likely location of the lesion?
 A. brainstem
 B. vestibulocochlear nerve
 C. spinal cord
 D. labyrinth

24. 2. A patient presents with vertigo, hearing loss, and
tinnitus. There are no other neurologic abnormalities.
Which is the following is the most likely location of
the lesion?
 A. brainstem
 B. vestibulocochlear nerve
 C. spinal cord
 D. cerebral cortex

25. 3. A patient describes short-lived episodes of vertigo
(rotary) precipitated by head movements, especially
when lying down (neck extension).
The vertigo usually lasts less than 45 seconds. There
are no other neurological symptoms except
nystagmus. What is the most likely diagnosis?
 A. Meniere’s disease
 B. Occlusion of the posterior inferior cerebellar artery
 C. Multiple sclerosis
 D. Benign paroxysmal positional vertigo (BPPV)

26. 4. A patient describes spells of vertigo lasting hrs,
preceded by ear fullness, tinnitus and hearing
dysfunction. No other neurological abnormalities.
What is the most likely diagnosis?
 A. Meniere’s disease
 B. Occlusion of the posterior inferior cerebellar artery
 C. Multiple sclerosis
 D. Benign paroxysmal positional vertigo (BPPV)

27. Key to Q&A
 1.A
 2.B
 3.D
 4.A