Vertigo

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Vertigo

• Tunde Magyar MD, PhD

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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

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Development of vertigo
Afferent Visual Proprioceptive Vestibular
CNS
Efferent Oculomotor Sceletal muscles Vegetative
Dizziness
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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.

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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.

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Examination of the patient with vertigo

• 2. Physical examination
• Spontaneous nystagmus
• Positional nystagmus
• Optokinetic nystagmus
• Posture and balance control
• Rombergs test
• Blind walking, Untenberger
• Báránys test
• Stimulations of labyrinth
• Caloric test (cold, warm water)
• Rotational test

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In case of vertigo
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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

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Differentiating peripheral and central vestibular
lesion

• 2. Central
• dysharmonicvestibular 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.

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Examination of the patient with vertigo

• 3. Laboratory examinations and imaging
• Electronystagmography
• Video-oculography
• Audiometry
• BAEP
• CT
• MRI

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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

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Duration of vertigo
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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!

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Left
Right
-
AC
AC
HC
HC
PC
PC

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BPPV diagnosis Dix-Hallpike manoeuvre
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BPPV therapy

• Medications not necessary
• Position training

Semont
Brandt-Daroff
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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

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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.

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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

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4. Menière disease

• Pathogenesis endolymphatic hydrops
• Therapy salt free diet, nicotin,
  alcohol-withdrawal, acetazolamide, betahistine

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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)

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Drug toxicity

• Aminoglycoside antibiotics
• Anticonvulsants
• Salycilates
• Alcohol
• Sedatives
• Antihistamines
• Antidepressants

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Other causes of vertigo

• Cervical spondylosis
• Sensory deprivation (neuropathy, visual
  impairment)
• Anemia
• Hypoglycaemia
• Orthostatic hypotension
• Hyperventilation