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1 V e r t i g o T ü n d e M a g y a r

2 Dizziness Vestibular Proprioception Optic input (afferentation) carries not Optic input (afferentation) carries not synchronizated information to the CNS, but contradictory to each other. (Büki)

3 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

4 What should be considered dizziness 1. Vertigo by medical personnel? A sense of feeling the environment moving when it does not. Mostly rotational movement. Persists in all positions. Aggravated by head movement. Typical of vestibular lesion. 2. Dysequilibrium/imbalance A feeling of unsteadiness or insecurity without rotation. Standing and walking are difficult. Common in parkinsonism and in diabetic polyneuropathy. 3. Light headedness Swimming, floating, giddy or swaying sensation in the head or in the room. Characteristic of psychiatric patients (anxiety, depression, hyperventilation sy). 4. Presyncope General weakness, pale face, sweating (orthostatic hypotension)

5 Epidemiology Dizziness (including vertigo and nonvestibular dizziness) is among the most common complaints in medicine, affecting approximately % of the population Prevalence of vertigo is 4.9%, incidence 1.4% Male: female=1:2.7 Prevalence increases with age, it is more common in elderly Curr Opin Neurol 2007;20:40-46.

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

7 Questions to be asked (taking the history) 1. 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 Loss of consciousness If episodic: sequence of events, activity at onset, aura, severity, amnesia etc.

8 Examination of the patient with vertigo 2. Physical examination BP, HR, Schellong test BP, HR, Schellong test Spontaneous nystagmus Positional nystagmus

9 Schellong test After 10 min supine position, the subject is required to stand for min, during which time the BP is measured continuously; A fall of systolic pressure of 20 mm Hg or more and/or decreasing of diastolic BP more than 10 mmhg indicates orthostatic hypotension. Cardiac arrhythmias, BP, orthostatic hypotension

10 Spontaneous nystagmus Fast and slow component Direction of nystagmus is described according to fast movement Horizontal, vertical, rotatory Intensity: I. degree: when present only on deviation of the eyes II. degree: when also present looking straight forward III. degree: when visible even on gaze in the direction opposite to the fast beat

11 Positional nystagmus: Dix-Hallpike manoever

12 Posture and balance control Romberg s test Blind walking, Untenberger Bárány s test Stimulations of labyrinth Caloric test (cold, warm water) Rotational test

13 Examination of the patient with vertigo 3. Laboratory examinations and imaging Electronystagmography Video-oculography Audiometry BAEP CT MRI

14 In case of vertigo No sponteous nystagmus Posture and balance control negative Sponteous nystagmus Posture and balance control positive Nausea vomiting Sweating, tachycardia Nausea, vomiting, sweating, anxiety GI disorder Chest pain Anxiety Harmonic Dysharmonic vestibular sy vestibular sy Internal medicine Angina, MI Loss of hearing, tinnitus Cardiology Psychiatry Vestibular neuronitis, Meniére disease Otology Numbness, double vision, dysarthria Brainstem infarct Neurology

15 Differentiating peripheral and central vestibular lesion 1. 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

16 Differentiating peripheral and central vestibular lesion 2. Central dysharmonic vestibular 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.

17 peripheral central Nystagmus horizontal, unidirectional vertical nystagmus implies central lesion, direction of horizontal nystagmus can change with the direction of gaze Nystagmus latency latency before onset, transient, <1 min no latency; or persistent >1 min Vertigo severe, often rotational mild Nausea, vomiting usually present usually absent Hearing loss, tinnitus frequently present absent Cranial nerve or brainstem signs absent often present Tendency to fall to the side opposite the nystagmus to the side of nystagmus

18 Common causes of vertigo 1. Peripheral Benign paroxysmal positional vertigo (18.3%) Vestibular neuronitis (7.9%) Labyrinthitis Meniére disease (7.8%) Vestibular paroxysmia (2,9%) Posttraumatic Perilymph fistula (0,4%) Toxins, medications

19 Common causes of vertigo 2. Central Brainstem TIA/infarct Posterior fossa tumors Multiple sclerosis Cerebellar stroke Syringobulbia Arnold - Chiari deformity Temporal lobe epilepsy Vestibular/basilar migraine

20 Common causes of dizziness 3. Other a) Presyncope Cardiac arrhythmias Vasovagal syncope Orthostatic dysregulation b) Dysequilibrium Parkinson sy Diabetic neuropathy c) Light-headedness Hyperventilation sy Anxiety

21 Common causes of dizziness 3. Other Metabolic reasons Hypoglycemia Disturbances of electrolite homeostasis (hypercalcemia, hyponatremia) Anemia Intoxication Alcohol Medications, drugs Toxins

22 Peripheral types of vertigo 1. 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!

23 2. Vestibular neuronitis Common in spring and early summer Sudden severe vertigo harmonic vestibular syndrome No cochlear symptoms (tinnitus, hearing loss) Reduced caloric reaction on affected side Recurrent attacks Lasts for several days

24 2. Vestibular neuronitis Reason: viral infection Therapy: 1-3. days. bedrest, vestibular suppressants (diazepam, clonazepam) antiemetics, vitamin B antiviral agents (?), corticosteriods(?) From 3. day: position training 3. Labyrinthitis, neurolabyrinthitis As vestibular neuronitis, but there are also cochlear symptoms.

25 4. Menière disease Menière 1861: glaucoma of the inner ear Prevalence: 43/ Male:female=1:1.3 Very strong familial trend for Menière disease is showed, up to 20% of family members have similar symptoms In early stage unilateral, about 35% of the cases become bilateral after 10 years

26 4. Menière disease Recurrent, spontaneous episodic vertigo Vertigo lasts for at least 20 min Horisontorotatory nystagmus always present Severe vegetative signs (nausea, vomiting, sweating) Sense of pressure in the ear Distorsion of sounds Sensitivity to noises Tinnitus Progressive hearing loss, unilateral first Lancet 2008:372:406-14

27 4. Menière disease Pathogenesis: endolymphatic hydrops, malabsorption of endolymph, rupture of membran

28 Treatment Prophylactic therapy: HCT+triamterene acetazolamide chlorthalidone Treatment of attacks: 1mg/kg prednisolon for days p.o. 4mg/ml dexamethason for 5 days it. Lancet 2008:372:406-14

29 5. Vestibular paroxysmia Short attacks of rotational vertigo lasting seconds to minutes Attacks frequently dependent on particular head positions Hypacusis, tinnitus permanently or during the attacks Measurable auditory or vestibular deficits by neurophysiological methods Carbamazepine effective Reason: neurovascular compression of VIIIth cranial nerve Neurology 2008:71:

30 6. Posttraumatic Direct or indirect trauma can affects labyrinth: Causes hemorrhage, longitudinal and transverse petrous bone fractures, perilymphatic fistula. After head trauma (commotio cerebri ) chr. vertigo may present.

31 7. Perilymphatic fistula Fistula of the oval or round window Hearing loss, tinnitus with or without vertigo Sudden changes of pressure in the middle ear (weight lifting, diving, nose blowing, cough) Positive fistula sign: nystagmus can provocate Positive fistula sign: nystagmus can provocate by pressure change in external ear canal

32 8. Oto- or vestibulotoxicity Cytostatics: vincristine, cisplatin Antibiotics: gentamycin, streptomycin, netilmycin, tobramycin, vancomycin Furosemide Sulfonamide Quinins Aspirin, NSAID-s CO, Hg

33 Central types of vertigo

34 1. Brainstem infarction

35 2. Brainstem and cerebellar metastasis

36 3. Multiple sclerosis

37 4. Cerebellar stroke

38 5. Syringobulbia-myelia

39 6. Arnold-Chiari malformation

40 7. Temporal epilepsy short, severe rotational postural vertigo sensory partial epileptic seizure rare

41 8. Vestibular migraine precipitated by irregular sleep, alcohol intake, certain foods before the episodic occipital headache (migraine) recurrent attacks of vertigo, ataxia, diplopia, nystagmus lasts for minutes to hours more common in females familiar pattern - migraine

42 Duration of vertigo Time Peripheral Central Seconds BPPV VB-TIA, aura of epilepsy Minutes perilymph fistula VB-TIA, aura of migraine (Half) hours Meniére disease basilar migraine Days Weeks, Month vestibular neuronitis labyrinthitis acustic neurinoma, drug toxicity VB stroke multiple sclerosis cerebellar degenerations

43 Other causes of vertigo 1. Kinetosis 2. Cervical spondylosis 3. Sensory deprivation (neuropathy, visual impairment) 4. Anemia 5. Hypoglycaemia 6. Orthostatic hypotension 7. Hyperventilation

44 Kinetosis (motion sickness) physiological overstimulation mainly vegetative symptoms: nausea, vomiting, pale face, bradycardia, sweating, precollapsus visual fixation can help antihistamins: dimenhydramine, promethazine

45 Cervical spondylosis, cervical vertigo Is still controversial Somatosensory vertigo C1/2, C6/7 spondylarthrosis Disturbed proprioception causes postural imbalance Neck pain, ataxia, gait imbalance, nystagmus after neck turning

46 Orthostatic hypotension Orthostatic (postural) hypotension is an excessive fall in BP when an upright position is assumed. The consensus definition is a drop of > 20 mm Hg systolic, 10 mm Hg diastolic, or both. Symptoms of faintness, dizziness, confusion, or blurred vision occur within seconds to a few minutes of standing and resolve rapidly on lying down. Reasons: hypovolemia medication side effects prolonged bed rest adrenal insufficiency autonomic dysfunction (multisystemic atrophy)

47 Hyperventilation common in panic attack anxiety hyperventilation, tachycardia, light- headedness relative hypocalcemia, carpopedal spasmus anxiolytics, breathing in plastic bag

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