Evaluation and Management of Dizziness and Vertigo

Peripheral vestibulopathy

Anatomy of VestibuloVestibulo-Cochlear System

Maintenance of balance
Higher centers : * Extra pyramidal system * Cerebellum * Reticular formation
(Sensory systems) ( Effector pathways ) Perception of orientation (in Vestibular cortex) Oculomotor system (Vestibulo-ocular reflex) Antigravity muscles controlling posture & gait (Vestibulo spinal reflex)

Vision

Brain stem integrating center (Vestibular nuclei)

Proprioception Vestibular labyrinths

Vertigo
Illusion of movement of the patient or patient s surroundings May be described as swaying rotatory, spinning, tilting or

Accompanying symptomssymptoms nausea, vomiting, diaphoresis, apprehension  Disequilibrium  nystagmus.

Disturbance in the peripheral or central nervous system

Dizziness
An ambiguous term that patients use to describe several entirely different subjective states. The complaint of dizziness generally can be divided into 1 of 4 categoriescategories1. Vertigo 2. Syncope or presyncope 3. Disequilibrium 4. Ill-defined dizziness Ill-

Syncope
Sense of impending loss of consciousness or fainting. (When the cerebral perfusion falls below the level required to maintain O2 and glucose to the brain) Causes: Cardiac

Vasovagal Arrhythmias Obstructive Carotid sinus syndrome

Orthostatic hypotension- Drug induced hypotensionVolume depleted Autonomic insufficiency

Disequilibrium
Sense of imbalance, unsteadiness or drunkenness without vertigo. Mismatch of inputs from systems subserving spatial orientation e.g. vestibular, proprioceptive, cerebeller, visual or extra pyramidal systems. Causes :
Multiple sensory deficits Cerebeller dysfunction NonNon-functioning labyrinths Extra pyramidal disorders Post. fossa tumour Drug intoxication

IllIll-defined dizziness :
(Other than vertigo, syncope, or disequilibrium)
Usually a vague light- headedness, giddiness lightor fear of falling. Causes: Hyperventilation syndrome Anxiety neurosis Hysterical neurosis Affective disorders Depression

Vertigo
Causes :
 Peripheral

- Physiologic (motion sickness) - Vestibular neuronitis - Benign positional vertigo - Menieres disease - Post-traumatic vertigo Post- Labyrinthine imbalance - Brain-stem ischemia Brain- Multiple sclerosis - Post. Fossa tumour - Basilar migraine

 Central

Types of dizziness and vertigo

Sensation of motion (vertigo): central or peripheral? Sensation of black-out (near-syncope): hypoperfusion (hypotension or cardiac origin) Disequilibrium: with one of multiple sensory deficits (visual, propioceptive, cerebellar) Ill-defined (head discomfort): mild headache, anxiety, depression or hyperventilation syndrome

Dizziness
1. Black-out: hypoperfusion (hypotension or cardiac origin) 2. Disequilibrium: Some sensory deficits 3. Head discomfort: mild headache, anxiety, depression or hyperventilation syndrome Watch for unsteady gait Dizziness is more complicated

Black-out (near syncope)

Postural hypotension [autonomic dysfunction ( esp. DM ), drug-induced, elderly, debilitated or volume depletion] Anemia Cardiac arrhythmia Obstructive (aortic or carotid stenosis) Vasovagal syncope Vertebro-basilar insufficiency (VBI) Subclavian steal syndrome

D/D of vertigo
The identification of central or serious vertigo was voted as the top priority for clinical decision rule development in adults The CT is not good enough; The MRI is not available right now. The most effective way to rule-out a central disorder is to rule-in a specific peripheral vestibular disorder.

Peripheral vestibulopathy
Vestibular neuronitis Benign paroxysmal positional vertigo (BPPV) Menieres disease Post-traumatic vertigo Viral or bact. labyrinthitis Acoustic neuroma Motion sickness

Vestibular neuritis
The most common cause of acute severe vertigo. It is caused by a viral lesion of the eighth cranial nerve. Vertigo is accompanied by severe nausea, vomiting, and imbalance. Typically hearing is not affected, but if severe vertigo is accompanied by hearing loss then the most common cause is labyrinthitisalso of a presumed viral etiology. The hallmark examination signs of vestibular neuritis are a spontaneous unidirectional horizontal nystagmus. Patients with vestibular neuritis are typically debilitated for the first day. The natural history of the disorder is a gradual recovery over weeks to months.

Menieres disease
Menieres disease patients are probably less likely to present to the emergency department during acute attacks compared with those with acute severe vertigo. The reason may be that Menieres disease attacks are typically limited to a few hours, and patients learn over time that the attacks resolve with rest. Unilateral hearing loss, which is typically a fluctuating symptom early in the course, but then becomes a fixed and progressive feature. Unilateral tinnitus (typically a low roaring sound rather than a high pitched sound) or bothersome pressure in one ear

Benign paroxysmal positional vertigo

The episodes are triggered by head movements, not simply worsened by head movements. It is important to know that dizziness of any cause can worsen after certain position changes. The patient with constant vertigo who reports that the symptom is better in a certain position and worse with movement should be classified as having acute severe vertigo rather than BPPV The vertigo attacks last less than one minute, followed by a return to normal. Some patients have dizziness between paroxysmal positional vertigo

Central Vestibulopathy
Brainstem stroke or lesion Cerebellar infarct, hemorrhage or tumor Drug-induced ( phenytoin overdose, Tegretol intolerance, aminoglycoside etc )

Lobes: flocculonodular, anterior, posterior has tonsils Vertical division vermis (midline) paravermis, lateral hemispheres Both divisions correspond to vestibulovestibulo- (arche), spinospino- (paleo) , pontoponto- (neo) erebellum

Coordination
Arm bounce Finger-nose test: dysmetria, intentional tremor Heel-knee-shin test: cerebellar or sensory ataxia , Past pointing:
. (lesion side) (cerebellar and vestibular lesions vestibular ) past pointing cerebellar

Rapid alternating movement:

(Dysdiadochokinesia)

Coordination
Romberg test
cerebellar deficit (cerebellar ataxia) (positive Rombergs sign) proprioceptive deficit (sensory ataxia)

Tandem gait:

History taking
l.Ear Problem: ear pain or fullness sensation, tinnitus (unilateral), hearing impairment. 2.Cardiovascular Problem: arrhythmia, orthostatic hypotension. 3.Diplopia, dysphagia, dysarthria, drop attack, numbness or weakness of the face or body. 4.Drug history.

Neurological examination
l. Nystagmus: gaze-evoked, positional (and gazepositioning). 2. Cranial nerve lesion and brainstem sign. 3. Cerebellar sign. 4. Any long tract sign.

Characteristics of nystagmus
Unidirectional or multidirectional ? Horizontal, rotary(torsional) or vertical? More severe than vertigo? (central) Milder than vertigo? (peripheral) : due to visual inhibition Duration? latent? fatique? (Dix-Hallpike (Dixmaneuver for positional nystagmus)

SEMINARS IN NEUROLOGY/VOLUME 29, NUMBER 5 2009

BPPV

Benign Paroxysmal Positional Vertigo(BPPV)

Most common Precipitated by movement or position change in the head or body Lasts only a few seconds Aetiology:
Head trauma Stapedectomy Intoxication alcohol , barbiturates Canelithiasis most common

Course

variable

subsides spontaneously in weeks recurs months or years later

Otolithic membrane of the macula showing the organization of calcium carbonate otoliths

ANATOMY & PHYSIOLOGY

BPPV by canal type

Posterior Horizontal Anterior

Estimated frequency Provocative maneuver Nystagmus

8181-89%

8-17%

1-3%

Dix Hallpike Upbeat, torsional

Supine Roll Test (Pagnini-McClure) PagniniHorizontal Direction Changing

Dix Hallpike Downbeat, torsional

Dix DixHallpike positioning maneuver

Supine head turn maneuver

Canalith repositioning maneuver (Epley maneuver)

Semont liberatory maneuver

Lempert 360- (Barbeque) degree roll 360maneuver

Forced prolonged position maneuver ( )12

Treatment
1. Antihistamine: Vena IM or IV, meclizine, merislon etc 2. Anticholinergic: Artane, akineton. 3. Phenothiazine: Novamin, primperan. 4. Sympathomimetic: Amphetamine, ephedrine. 5. Benzodiazepine: 6. Circulation improver: Diphadol, sanyl, suzin (sibelium), perdipine etc... 7. Other: Dogmatyl, wintermin

Case 1
68 y/o female Dizziness Nausea and vomiting 99/8/4

Case 2
50y/o female Dizziness Revisit ER again Vertical nystagmus 99/7/26

Case 3
56 y/o female Dizziness Lt hand dysmetria 99/9/3

Case 4
80y/o female Falling down accident Dizziness Mild nausea sensation 100/4/3