VertigoVertigo andand dizzinessdizziness:: differential differential diagnostics and individual diagnostics and individual

treatment procedurestreatment procedures

Trinus K.

P.L.Shupyk National Medical Academy for Postgraduate Education, Ukraine, Kyiv

Vertigo -Vertigo -

- - a disturbance in which a disturbance in which the individual has a the individual has a subjective impression subjective impression of movement in space of movement in space (subjective(subjective vertigovertigo)) or or objects moving around objects moving around him (objectivehim (objective vertigovertigo),), usually with a loss of usually with a loss of equilibriumequilibrium

True vertigoTrue vertigo is distinguished is distinguished from from faintness, light-faintness, light-headedness,headedness, or other forms of or other forms of “dizziness”,“dizziness”, results from results from disturbance somewhere in the disturbance somewhere in the equilibratory apparatus: equilibratory apparatus: vestibule, semicircular canals, vestibule, semicircular canals, 88thth nerve,... or eyes. nerve,... or eyes.

The Merck Manuel

DizzinessDizziness

- - distortion of the perceptiondistortion of the perception of of space and movementspace and movement..

Some authors consider distortion of Some authors consider distortion of the time perception to be the sign of the time perception to be the sign of

dizzinessdizziness..

VertigoVertigo- - Illusion of the nonexistent movementIllusion of the nonexistent movement::

more often rotatorymore often rotatory, , seldom swaying or seldom swaying or linear movement forward -linear movement forward - backwardbackward, , aside,aside, up and downup and down..

DizzinessDizziness Light-headednessLight-headedness Black-outsBlack-outs GiddinessGiddiness NumbnessNumbness FaintnessFaintness ConfusionConfusion ClaustrophobiaClaustrophobia SyncopeSyncope

Coordination disorders (disequilibria)Coordination disorders (disequilibria)

– – bbalance disorder might be without alance disorder might be without dizzinessdizziness, , indicating presumably indicating presumably lesion of motor systemslesion of motor systems..

Patients are complaining ofPatients are complaining of: :

““I am going like drunkardI am going like drunkard, , swayingswaying, , short short coordination disturbancescoordination disturbances, , as if being pushed as if being pushed asideaside...” ...”

Material and methodsMaterial and methods

During During 1983-2003 1541983-2003 154 persons have been examined with average persons have been examined with average age ofage of 34.36±11.2334.36±11.23..

All the patients have been complaining of vertigo-dizziness attacks All the patients have been complaining of vertigo-dizziness attacks during last during last 5-7 5-7 yearsyears. .

Vestibular dysfunction has been documented instrumentally by Vestibular dysfunction has been documented instrumentally by increased of the VestEP peak latencies while somatosensory, increased of the VestEP peak latencies while somatosensory, acoustic, visual being normal, presence of nystagmusacoustic, visual being normal, presence of nystagmus, , and also and also balance disorders of middle level according to cranio-corpography balance disorders of middle level according to cranio-corpography datadata..

Subjective sensations during caloric Subjective sensations during caloric testtest

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Nystagmus frequencyNystagmus frequency ( (per per 1 1 minmin.) .) p = 0,04 (F test)p = 0,04 (F test)

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Nystagmus frequencyNystagmus frequency Nystagmus might be

physiological and pathological

Pathological nystagmus depending from frequency characterize hypo- or hyperreflectivity

Hair cellsHair cells TypeType І І – – bigbig, , vase-vase-

likelike, , situated situated compactly in the compactly in the center of the receptor center of the receptor structurestructure

TypeType ІІ ІІ – – smallsmall, , cylindricalcylindrical, , dispersed dispersed in macula and cupulain macula and cupula..

Vestibular nerveVestibular nerve Consist of peripheral portion innervating hair cells, vestibular ganglionConsist of peripheral portion innervating hair cells, vestibular ganglion, , where where

the soma of the bipolar cells are localized and axons, proximally directed from the soma of the bipolar cells are localized and axons, proximally directed from these cells and composing central portion of the nervethese cells and composing central portion of the nerve. . The number of the The number of the neurons in the ganglion is neurons in the ganglion is 77..000000--1818..000. 000. Each of peripheral receptors receives Each of peripheral receptors receives approximately equal amount of the fibersapproximately equal amount of the fibers..

The major difference of vestibular nerve from all the other sensory nerves is The major difference of vestibular nerve from all the other sensory nerves is presence of thick fiberspresence of thick fibers, , diameter of which exceeds diameter of which exceeds 5 µ 5 µ and the number of which and the number of which reachesreaches 10%. 10%.

Average diameter of the vestibular nerve fibers is Average diameter of the vestibular nerve fibers is 3-4 µ. 3-4 µ. The fibers are packed The fibers are packed in severe orderin severe order: : in the peripheral portion thick fibers are localized centrallyin the peripheral portion thick fibers are localized centrally, , while thin - peripherallywhile thin - peripherally. . At the ganglion level thick fibers are placed At the ganglion level thick fibers are placed dorsocranially in the central part of the nerve.dorsocranially in the central part of the nerve. Soma dimensions correlates with Soma dimensions correlates with the fiber diameterthe fiber diameter. . For thin fibers the oval-shape neurons with average diameters For thin fibers the oval-shape neurons with average diameters of the soma 15 and 22 µ are typicalof the soma 15 and 22 µ are typical, , and for the thick onesand for the thick ones - 22 - 22 andand 40 40 µ. µ.

Vestibular nucleiVestibular nuclei

ThickThick fibersfibers terminating terminating mostly in the central part mostly in the central part of the upper vestibular of the upper vestibular nucleusnucleus,, where big neurons where big neurons are locatedare located, , vestibulo-vestibulo-ocular by functionocular by function..

Terminals of theTerminals of the thin fibersthin fibers are dispersed in all the are dispersed in all the vestibular nuclei.vestibular nuclei.

Vestibular pathwaysVestibular pathways

Thick fibersThick fibers of the vestibular nerve participate in of the vestibular nerve participate in the generation of high frequency nystagmusthe generation of high frequency nystagmus, , related torelated to vertigovertigo..

DizzinessDizziness therefore is related totherefore is related to thin fibers.thin fibers.

Vestibulo-cortical pathwaysVestibulo-cortical pathways Cognition of the sensory information is finalized at the brain Cognition of the sensory information is finalized at the brain

cortexcortex. . It is proved to be several pathways between vestibular It is proved to be several pathways between vestibular periphery and cortical vestibular zoneperiphery and cortical vestibular zone..

The shortest one is projecting to the contralateral suprasilvian The shortest one is projecting to the contralateral suprasilvian girusgirus and is characterized with the latency of response in the and is characterized with the latency of response in the ranges ofranges of 3-5 м 3-5 мss. . This pathway is considered to have only two This pathway is considered to have only two synaptic transmissionssynaptic transmissions..

Evoked responsesEvoked responses recorded from the ipsilateral hemisphere recorded from the ipsilateral hemisphere have bigger latencyhave bigger latency - - aboutabout 8 м 8 мss, , and their amplitude and their amplitude depended from the type of narcosisdepended from the type of narcosis, , thus indicating bigger thus indicating bigger amount of synaptic transmissions.amount of synaptic transmissions.

In physiological conditionsIn physiological conditions

VertigoVertigo is is initiated by initiated by rotationsrotations.. DizzinessDizziness is is

initiatedinitiated bybyhyperventilationhyperventilation

In pathological conditionsIn pathological conditions

VertigoVertigo

is typical foris typical for:: CupulolithiasisCupulolithiasis BPPVBPPV Vestibular neuritisVestibular neuritis Meniere diseaseMeniere disease

DizzinessDizziness

is typical foris typical for:: IntoxicationsIntoxications Chronic diseasesChronic diseases

Methods for documentationMethods for documentation

1. 1. besides Nystagmography besides Nystagmography

2. 2. Evoked potentialsEvoked potentials

3. 3. Cranio-corpographyCranio-corpography ( (postulographypostulography))

Vestibular lesionVestibular lesion

EPEP NN vestib vestib acoustacoust visualvisual olfactolfact somatosenssomatosens

P1 P1 (40) (40) 118118 (60) 40 (60) 40 (60) (60) 5555 (140)(140) 135 (80) 72 135 (80) 72

N1 N1 (80)(80) 146146 (100) 76 (100) 93 (100) 76 (100) 93 (230)(230) 210 210 (150) 147(150) 147

P2 P2 (150) (150) 117878 (180) (180) 150150 (180)147 (180)147 (300)(300) 291 (200) 178 291 (200) 178

•Increased latencies of all the peaks of the vestibular EP while Increased latencies of all the peaks of the vestibular EP while the other Eps are normalthe other Eps are normal – – indicates central and peripheral indicates central and peripheral vestibular dysfunctionvestibular dysfunction. .

Typical forTypical for vertigovertigo

Vestibular dysfunctionVestibular dysfunction

EPEP NN vestib vestib acoustacoust visualvisual olfactolfact somatosenssomatosens

P1 P1 (40)(40) 5353 (60) 40 (60) 40 (60) (60) 5555 (140)(140) 135 (80) 72 135 (80) 72

N1 N1 (80)(80) 9696 (100) 76 (100) 93 (100) 76 (100) 93 (230)(230) 210 210 (150) 147(150) 147

P2 P2 (150) (150) 150150 (180) (180) 150150 (180)147 (180)147 (300)(300) 291 (200) 178 291 (200) 178

•Increased PIncreased P11 and N and N11 of the vestibular EP indicate of the vestibular EP indicate maximal maximal

dysfunction in the peripheral, brainstem and subcortical parts dysfunction in the peripheral, brainstem and subcortical parts of the vestibular systemof the vestibular system. . Typical for Typical for dizzinessdizziness ( (for example for example Chornobyl clean-uppersChornobyl clean-uppers, 884 , 884 persons examinedpersons examined))

Coordination disturbanceCoordination disturbanceEPEP NN vestibvestib acoustacoust visualvisual olfactolfact somatosenssomatosens

P1 P1 (40(40) 37) 37 (60) 40 (60) 40 (60) (60) 5555 (140)(140) 135 (80) 72 135 (80) 72

N1 N1 (80)(80) 72 72 (100) 76 (100) 76 (100) 93 (100) 93 (230)(230) 210 210 (150) 147(150) 147

P2 P2 (150) (150) 148148 (180) (180) 150150 (180)147 (180)147 (300)(300) 291 (200) 178 291 (200) 178

Might be not accompanied with vestibular Might be not accompanied with vestibular dysfunction according to EP recordingdysfunction according to EP recording

Methods for balance evaluationMethods for balance evaluation

Balance Balance function is function is documented documented with the help of with the help of cranio-cranio-corpographycorpography ((postulographypostulography))

Typical cases of the CCGTypical cases of the CCG

Left figure – wide Left figure – wide undulations during undulations during steppingstepping test typical test typical for the for the central central lesionslesions of the lower of the lower portion of brain portion of brain stemstem

Right figureRight figure peripheral lesionperipheral lesion ((right labyrinthright labyrinth))

Differential diagnosticsDifferential diagnosticsDizzinessDizziness VertigoVertigo Balance Balance

disorderdisorder

ComplaintsComplaints UnclearUnclear Clear Clear descriptiondescription

TypicalTypical

VestEPVestEP

Increased Increased latencies oflatencies of Р1Р1 and and NN11

Increased all Increased all latencieslatencies

Might be normalMight be normal

NystagmoNystagmo

graphygraphy

Low Low frequencyfrequency

High High frequencyfrequency

Might be Might be presentpresent

BalanceBalance Small Small disturbancedisturbance

Severe Severe disturbancedisturbance

DisturbanceDisturbance

Effect of Tanakan at the symptomatics of vertigo-dizziness, horizontal axis - % of patients, vertical - symptoms

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DizzinessDizziness

In the case ofIn the case of hyporeflexiahyporeflexia

TanakanTanakan

Effect of Cinnarizine at the dizziness-vertigo

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VertigoVertigo In the case of In the case of

hyperreflexiahyperreflexia treatment must be in treatment must be in two phasestwo phases::

1. 1. Medicaments with Medicaments with sedative activitysedative activity

2. 2. After managing After managing hyperreactivityhyperreactivity --activation of the plastic activation of the plastic processes processes – – drugs drugs with nootropic effectwith nootropic effect

Vertigo and dizziness originates in the vestibular system;

The difference in the effect of therapy at vertigo and dizziness (black-outs, lightheadedness) is evident;

There is no difference in the effect of therapy at dizziness, black-outs, light-headedness etc.

NB!NB!

Strict differentiation of the Strict differentiation of the complaints might be the first complaints might be the first

step for the correct step for the correct diagnostics and treatment diagnostics and treatment

choicechoice..

Complaints distributionComplaints distribution

% patients

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Patient: P. 25 years old, military officerComplaints: intensive headaches without clear localization 1-3 times per week with 1-2 days duration and accompanied with severe vertigo and dizziness, hyperhydrosis, loss of consciousness and vomiting episodes.Labor capacities and quality of life are seriously decreased.

Anamnesis morbi:Anamnesis morbi:

Start of the disease - August 2001. After stress and overloading with computer use up to 12-14 hours per day.

According to medical documentation presented by the patient has been at the neurological department of the Central Military hospital from January 2002 till July 2003 at the stationary treatment.

Therapy with vascular, nootropic, dehydrative, sedative, analgesic, antimigrainous, desensibilizative, anticonvulsive, imunecorrective, antiviral and hormonal drugs has not given any positive effect, the frequency and intensity of the headache attacks preserved.

Morphium solution has not presented positive effect.

In July 2003 patient got II group of invalidity.

August 2003 has admitted to Neurootological Center.

Basing at the knowledge that migraine attacks have been accompanied with vertigo-dizziness, lack of the effect of previous therapy and objective neurootological data:

1.    Balance disturbances, 2.    Positive Takahashi test during ECG recording, 3.    Micronystagmus present, 4.    Dominant increase of the latencies of the Vestibular EPs, -

We have supposed vestibular nature of the headaches described. According to IDC 10 principal diagnosis:

Vestibular dysfunction (H 81). Status Migrainosus (G 43.2).

Positive effect of betahistine appeared at the first days of

treatment.

Intensity and duration of the headaches progressively decreased, vertigo and nausea disappeared, intervals between the attacks – increased.

By the end of the first month the migrainouse attacks totally disappeared!

Evoked potentialsEvoked potentials: : ((latency oflatency of PP11))

Decrease of the latencies of the EP peaks of all the systems after 1 month of treatment

Clear normative data after 9 months

Vertigo, dizziness and additional symptoms

Medicine of choice

betahistine

Differentiated approach to the treatment of vestibular migraine

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Cinnarizin Dimenhydrinate

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Conclusions 1. We have the reason to differentiate vertigo,

dizziness and disequilibrium 2. Vertigo and dizziness are generated by the

vestibular system 3. We have not enough evidence to differentiate

light-headedness, black-outs, confusion, faintness from dizziness

4. Vestibular migraine has its own specifics 5. Localization of the headache might be

important for the therapy selection

Pleasant Pleasant vertigo to vertigo to

everybodyeverybody!!