Vestibular Symptoms in Concussion: Medical/Surgical Perspective Jacob R. Brodsky, MD Boston Children s Hospital jacob.brodsky@childrens.harvard.edu
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
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
What does the vestibular system do? SENSES MOTION to maintain STABLE VISION and STABLE POSTURE
Semicircular Canals Encode Rotation
Otoliths Encode Linear Acceleration And Tilt
STABLE VISION HEAD EYES Vestibulo-ocular reflex (VOR)
Bedside DVA
STABLE POSTURE Vestibulo-spinal reflex (VSR)
BESS McLoed & Hale 2014
SOT
Putting it all Together Central Vestibular System Peripheral Vestibular System Vestibular Output Any of these components can be affected by concussion!
Dizziness after concussion is not a single entity! 1. Traumatic Vestibular Disorders 2. Post-Concussive Vestibulopathy 3. Oculomotor Disturbances
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
Benign Paroxysmal Positioning Vertigo BPPV
Diagnosis High-Resolution CT Superior Semicircular Canal Dehiscence Syndrome
Vertigo Hearing Loss Autophony Conductive Hyperacusis Sound-induced vertigo SYMPTOMS
VEMP test Vestibular Evoked Myogenic Potential (VEMP)
Enlarged Vestibular Aqueduct Syndrome EVAS SLC26A4 and Pendred s Syndrome Hearing loss +/- vestibular symptoms Minor head trauma SNHL & Vestibular loss Steroids? Avoid contact sports?
Enlarged Vestibular Aqueduct Syndrome EVAS
Perilymphatic Fistula Similar symptoms to SSCD Often normal CT and exam Usually hearing loss present PLF Video
Temporal Bone Fracture Usually (+) LOC Hemotympanum/otorrhea +/- hearing loss and/or facial paralysis Labyrinthine Concussion Hearing loss +/- vestibular loss Normal CT
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
Post-Concussive Vestibulopathy Temporal bone studies from major TBI Vestibular nerve traction Vestibular nucleus injury Is it different for concussion?
Alhilali et al. (Pitt) 2014 Increased fractional anisotropy (FA) in vestibular areas of cerebellum in patients with vestibular symptoms after concussion
Gottshall et al 2003 DVAT correlated with DHI at 1 week post-injury
Hoffer/Gottshall Classification 1. Exertional Dizziness 2. Migraine Associated Dizziness 3. Spatial Disorientation
1. Exertional Dizziness 2. Migraine Associated Dizziness Symptoms: Episodic Testing: Generally normal Treatment: Reconditioning/Habituation +/- Migraine Medications
3. Spatial Disorientation Symptoms: Constant Testing: Often abnormal Treatment: Specific to deficits Balance Deficits Balance exercises VOR Deficits Visual stability exercises
Balance Deficits 40% with low composite score 81% with a vestibular pattern Similar findings by Pickett 2007 & Guskiewicz 2008
VOR Deficits n Abnormal Rotation 41 9 22% Calorics 14 3 21% DVAT 23 13 57%
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