Vertigo

Balance system

Sensory input • Vestibular

apparatus • Vision • Propriocepti

on

Integrating mechanism • Vestibular

nuclei • Cerebellum • Extrapyrami

dal system • Limbic

system • Cerebral

cortex

Effector organ • Locomotor

system • Eye

movement

Difficult in diagnosis

• Complexity of balance system • Adaptation of system

– Uni-bilateral – Acute-chronic

• Varies of symptoms • Various etiology

– Systemic – Degeneration – Aging

Compensatory mechanism in human

• Vestibular compensation – Adaptation and learn new behavior – Rapid symptom recovery following peripheral

pathology • Variety of process

– Adaptation/habituation: recalibration of the gain of the vestibular reflex

– Substitution of sensory input and motor response, together with alteration of stretegies used for balance

Syndrome of vertigo: base on connection

Major symptoms • Vertigenous sensation • Imbalance • Nystagmus and

oscillopsia • Autonomic dysfunction

• N/V • Palpitation • Fluctuation in BP

• Psychiatric symptoms: fear – Anxiety – Hyperventilation

syndrome – Phobia

Interaction of autonomic, psychological, and vestibular symptoms

Dizzy symptoms

True vertigo

Non-vertigenous dizziness

• Syncope • Disequilibrium • Ill-define symptoms

S/S Peripheral Central Latency Duration Fatigability Nystagmus direction !Intensity of S/S !reproducibility

0-40 sec <1 min Yes Direction fixed, torsional, up, upper pole of eye toward ground Severe vertigo, nystagmus, nausea !Inconsistent

No latency May persist No Direction changing variable !Mild vertigo, less intense nystagmus, rare nausea More consistent

Identify causes•Otological disorder •Neurological disorder •Systemic disorder

Most helper differential causes

Time course - onset

Causes of vertigo

Peripheral vertigo• Infection/inflammation

– Peripheral vestibulopathy Vestibular neuritis, acute neurolabyrinthitis Localized: CN7+8 affected: Ramsay Hunt syndrome Systemic: mump, measle, IM, URI

• Trauma: post-traumatic vertigo • Local tumor • Vascular: rare • Metabolic/ toxic

– Aminoglycoside(rare) • Other: BPPV, Meniere’s disease

Central vertigoCommon is

• Tumor: CP angle tumor • Demyelinating: MS • Vascular: ischemia(VBI) • Posterior fossa lesion • Migraine • Vertigenous epilepsy

Systemic causes of vertigo and dizziness

• Drugs – AED, hypnotic, alcohol, analgesic

• Hypotension, presyncope • Infectious disease

– Syphilis, viral, systemic infection • Endocrine disease

– Diabetes, hypothyroidism • Vasculitis • Others: hematological, granulomatous

disease, systemic toxin

Some point

• Acute vestibular vertigo • Mimicker peripheral VS central • Some central cause: only vertigo S/S • Acute can caused by vascular VS non-

vascular • Episodic caused by various etiology • Pattern recognition: • Use anatomical and time course-onset

together

Time course-onsetLasting for day or longer • Peripheral: vestibular neuritis • Central: brainstem stroke, MS

Lasting for hours or minute • Peripheral: Meniere’s disease • Central: TIA, migraine, seizure

Lasting for second • Peripheral: BPPV

Vertigo lasting for day or longer

Vestibular neuritis• Acute • Few hours, peaks in day,

improve within day to weeks

• Viral or post viral?

Brain stem stroke• Sudden • Evidence of

vertebrobasilar ischemia • Some can mimick

peripheral cause: inferior cerebellar and flocculonodular lobe

Distinguishing vestibular neuritis from stroke(in absence of others brain stem signs)

Nystagmus• Direction • Fixation

Postural instability• Severity • Direction of instability

Peripheral vertigo management

Five main arms of management intervention: • General medical evaluation, with correction/

ameliorationnof associated morbid conditions • Pharmacological intervention • Vestibular rehabilitation with physiotherapy and

specific physical manoeuvres for the management of benign positional paroxysmal vertigo

• Psychological intervention • Surgery

Vascular cause of vertigo

Location of lesion• Paramedian infratentorial

lesion • Thalamus • Vertibular cortex

Vascular territory• Vertebrobasilar system • Middle cerebral artery