Vertigo. David Clark, DO Oregon Neurology Associates Springfield, OR

Transcription

1 Vertigo David Clark, DO Oregon Neurology Associates Springfield, OR

2 44F vertigo, nausea & vomiting Unidirectional Nystagmus

3 44F vertigo, nausea & vomiting Impaired VOR Gain to the right

4 Vertigo History Anatomy/Physiology Horses Zebras Acute management

5 The Dizzy Bubble Hypertension Sleep Disorder Gait imbalance Anemia Vertigo Hypo/hypergl ycemia Medication Effect Psychiatric Depression Anxiety Panic Orthostatic hypotension Patient may have difficulty articulating their experience clearly

6 History Tips Quality of symptom not very helpful Dizzy, Vertigo, Light headed Symptom duration helps narrow DDx Associated symptoms helpful Nausea Tinnitus Diplopia Focal neurologic deficits

7 Differential by Symptom Duration SSCC dehiscence Perilymphatic fistula BPPV** Migraine Ischemic (TIA,Stroke) Menieres Vestibular Neuritis Mass lesion Demyelinating Seconds Minutes Hours Days--Constant **BPPV may be perceived as lasting hours-days

8 Peripheral vs. Central

9 Pathophysiology of vestibular symptoms and signs: The clinical examination, DS Zee Neurology Continuum Aug 2006 pg 18 Tonic firing from each peripheral vestibular apparatus Tonic firing from each peripheral vestibular apparatus

10 Tonic firing from each peripheral vestibular apparatus Tonic firing from each peripheral vestibular apparatus Asymmetry of the tonic firing tells the brain there s movement

11 Lesion or overaction (BPPV) of the peripheral vestibular aparatus or its central connections creates asymmetry of tonic input and the sensation of movement

12 BPPV ~3% population Vertigo lasts seconds to minutes Provoked by head rotation Roll over in bed Look over shoulder Nausea/Vomiting 85-90% Queasy for hours in between

13 Dix Hallpike Semin Neurol. 2009;29(5):

14 Dix- Hallpike and Epley (Steps 1-5) Diagnosis and treatment for Right Posterior Canal BPPV Semin Neurol. 2009;29(5):

15 Epley Video

16 Semont For Right posterior canal BPPV Semin Neurol. 2009;29(5):

17 BPPV No central mimics of DH nystagmus Surgery Avoid chronic vestibular suppressants

18 Vestibular Neuritis Unidirectional nystagmus VOR Gain Steroids and antivirals Neurology 2011;76;e71 VOR Gain

19 Vestibular Nystagmus

20 Vestibular neuritis Slow Phase

21 Menieres Vertigo lasting minutes to hours Unilateral aural fullness and tinnitus Over time, low frequency sensorineural hearing loss Treat: diuretics, +/- steroids Intractable: intratympanic gentamycin, surgery

22 Migrainous Vertigo, ~1% population 1. History of Migraine 2. 1 migraine symptom during 2 episodes of vertigo 1. HA 2. Photophobia 3. Phonophobia 4. Visual aura 3. No better explanation for vertigo 4. Treat migraine

23 MS Diplopia and vertigo

24 Lung adenocarcinoma metastasis

25 Visually mediated dizziness Post concussive Migraine Prior vertigo

26 Vestibular Schanomma

27 Superior semicircular canal dehiscence Valsalva induced vertigo

28 Perilymphatic fistula NEJM 366;4 Perilymphatic fistula Test Can also see Tulio phenomenon

29 Vertebral artery dissection and cerebellar infarct

30 Bilateral Vestibular Loss Etiologies Aminoglycosides Irradiation Paraneoplastic Idiopathic B/L VOR gain Dynamic Visual Acuity Can t read and walk No vertigo if symmetric Static acuity 20/20 Dynamic acuity 20/100

31 Bilateral Vestibular Loss CANVAS Cerebellar ataxia Neuropathy Vestibular areflexia

32 Visual dizziness

33 Tardive dizziness following lesion to Mollaret s Triangle Dentate Red Nucleus Inferior Olive

34 Distinguishing central from peripheral

35 Peripheral Head impulse test: Abnormal Unidirectional nystagmus No vertical misalignment Central Head Impulse test: Normal Alternating nystgmus Skew deviation Skew video

36 Take home Historical keys Exam tools Dix-Hallpike Head impulse test Perilymphatic fistula test Valsalva Epley Differentiating central from peripheral vertigo in the acute setting

37 Questions