Vestibular Symptoms in Concussion: Medical/Surgical Perspective. Jacob R. Brodsky, MD Boston Children s Hospital
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1 Vestibular Symptoms in Concussion: Medical/Surgical Perspective Jacob R. Brodsky, MD Boston Children s Hospital jacob.brodsky@childrens.harvard.edu
2 On Field Symptoms Headache Dizziness Confusion Fatigue Vision changes Imbalance Vomitting Loss of Consciousness 95% 81% 66% 61% 56% 51% 14% 12% 6 x as likely to have protracted recovery
3 Protracted Dizziness At Injury Present > 1 week Present > 1 month Present > 3 months 61% 53% 14% 4% 4% of 3.8 million = >150,000 people per year with dizziness lasting > 3 months
4 What does the vestibular system do? SENSES MOTION to maintain STABLE VISION and STABLE POSTURE
5 Semicircular Canals Encode Rotation
6 Otoliths Encode Linear Acceleration And Tilt
7 STABLE VISION HEAD EYES Vestibulo-ocular reflex (VOR)
8
9 Bedside DVA
10 STABLE POSTURE Vestibulo-spinal reflex (VSR)
11 BESS McLoed & Hale 2014
12 SOT
13
14 Putting it all Together Central Vestibular System Peripheral Vestibular System Vestibular Output Any of these components can be affected by concussion!
15 Dizziness after concussion is not a single entity! 1. Traumatic Vestibular Disorders 2. Post-Concussive Vestibulopathy 3. Oculomotor Disturbances
16 Dizziness after concussion is not a single entity! 1. Traumatic Vestibular Disorders Benign Paroxysmal Positioning Vertigo (BPPV) Superior Semicircular Canal Dehiscence Syndrome Enlarged Vestibular Aqueduct Syndrome (EVAS) Perilymphatic Fistula Temporal Bone Fracture Labyrinthine Concussion
17 Benign Paroxysmal Positioning Vertigo BPPV
18
19
20 Diagnosis High-Resolution CT Superior Semicircular Canal Dehiscence Syndrome
21 Vertigo Hearing Loss Autophony Conductive Hyperacusis Sound-induced vertigo SYMPTOMS
22 VEMP test Vestibular Evoked Myogenic Potential (VEMP)
23 Enlarged Vestibular Aqueduct Syndrome EVAS SLC26A4 and Pendred s Syndrome Hearing loss +/- vestibular symptoms Minor head trauma SNHL & Vestibular loss Steroids? Avoid contact sports?
24 Enlarged Vestibular Aqueduct Syndrome EVAS
25 Perilymphatic Fistula Similar symptoms to SSCD Often normal CT and exam Usually hearing loss present PLF Video
26 Temporal Bone Fracture Usually (+) LOC Hemotympanum/otorrhea +/- hearing loss and/or facial paralysis Labyrinthine Concussion Hearing loss +/- vestibular loss Normal CT
27 Traumatic Vestibular Disorders Dix-Hallpike BPPV Repositioning Maneuvers Peripheral Symptoms - Hearing loss - Tinnitus - Hyperacusis - Sound-induced vertigo SSCD or PLF Surgery vs. Observation Peripheral Battery Audiogram VEMP +/- CT temporal bone EVA or TBF or LC Vestibular Rehab +/- Steroids
28 Post-Concussive Vestibulopathy Temporal bone studies from major TBI Vestibular nerve traction Vestibular nucleus injury Is it different for concussion?
29 Alhilali et al. (Pitt) 2014 Increased fractional anisotropy (FA) in vestibular areas of cerebellum in patients with vestibular symptoms after concussion
30 Gottshall et al 2003 DVAT correlated with DHI at 1 week post-injury
31 Hoffer/Gottshall Classification 1. Exertional Dizziness 2. Migraine Associated Dizziness 3. Spatial Disorientation
32 1. Exertional Dizziness 2. Migraine Associated Dizziness Symptoms: Episodic Testing: Generally normal Treatment: Reconditioning/Habituation +/- Migraine Medications
33 3. Spatial Disorientation Symptoms: Constant Testing: Often abnormal Treatment: Specific to deficits Balance Deficits Balance exercises VOR Deficits Visual stability exercises
34 Balance Deficits 40% with low composite score 81% with a vestibular pattern Similar findings by Pickett 2007 & Guskiewicz 2008
35 VOR Deficits n Abnormal Rotation % Calorics % DVAT %
36 General Approach Rule out peripheral disorders Dix-Hallpike, Audiogram +/- VEMP & CT Treat migraine, if present Directed vestibular rehabilitation Exertional Sx Reconditioning/ Habituation Balance impairment: BESS Balance retraining VOR: DVA/HIT/VOMS Visual stability exercises CI Convergence exercises
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Original Research Pediatric Otolaryngology Peripheral Vestibular Disorders in Children and Adolescents with Concussion Otolaryngology Head and Neck Surgery 2018, Vol. 159(2) 365 370 Ó American Academy
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