![Page 1: Vertigo - cdn.ymaws.com · Unidirectional Nystagmus . 44F vertigo, nausea & vomiting Impaired VOR Gain to the right . Vertigo • History • Anatomy/Physiology • Horses • Zebras](https://reader036.vdocuments.net/reader036/viewer/2022081606/5e19c7bda92af10936156d26/html5/thumbnails/1.jpg)
Vertigo David Clark, DO
Oregon Neurology Associates
Springfield, OR
![Page 2: Vertigo - cdn.ymaws.com · Unidirectional Nystagmus . 44F vertigo, nausea & vomiting Impaired VOR Gain to the right . Vertigo • History • Anatomy/Physiology • Horses • Zebras](https://reader036.vdocuments.net/reader036/viewer/2022081606/5e19c7bda92af10936156d26/html5/thumbnails/2.jpg)
44F vertigo, nausea &
vomiting
Unidirectional Nystagmus
![Page 3: Vertigo - cdn.ymaws.com · Unidirectional Nystagmus . 44F vertigo, nausea & vomiting Impaired VOR Gain to the right . Vertigo • History • Anatomy/Physiology • Horses • Zebras](https://reader036.vdocuments.net/reader036/viewer/2022081606/5e19c7bda92af10936156d26/html5/thumbnails/3.jpg)
44F vertigo, nausea &
vomiting
Impaired VOR Gain to the right
![Page 4: Vertigo - cdn.ymaws.com · Unidirectional Nystagmus . 44F vertigo, nausea & vomiting Impaired VOR Gain to the right . Vertigo • History • Anatomy/Physiology • Horses • Zebras](https://reader036.vdocuments.net/reader036/viewer/2022081606/5e19c7bda92af10936156d26/html5/thumbnails/4.jpg)
Vertigo
• History
• Anatomy/Physiology
• Horses
• Zebras
• Acute management
![Page 5: Vertigo - cdn.ymaws.com · Unidirectional Nystagmus . 44F vertigo, nausea & vomiting Impaired VOR Gain to the right . Vertigo • History • Anatomy/Physiology • Horses • Zebras](https://reader036.vdocuments.net/reader036/viewer/2022081606/5e19c7bda92af10936156d26/html5/thumbnails/5.jpg)
The Dizzy Bubble
Vertigo
Sleep
Disorder Gait
imbalance
Medication
Effect
Psychiatric
Depression
Anxiety
Panic Anemia
Hypertension
Hypo/hypergl
ycemia
Orthostatic
hypotension
Patient may have
difficulty articulating
their experience clearly
![Page 6: Vertigo - cdn.ymaws.com · Unidirectional Nystagmus . 44F vertigo, nausea & vomiting Impaired VOR Gain to the right . Vertigo • History • Anatomy/Physiology • Horses • Zebras](https://reader036.vdocuments.net/reader036/viewer/2022081606/5e19c7bda92af10936156d26/html5/thumbnails/6.jpg)
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
![Page 7: Vertigo - cdn.ymaws.com · Unidirectional Nystagmus . 44F vertigo, nausea & vomiting Impaired VOR Gain to the right . Vertigo • History • Anatomy/Physiology • Horses • Zebras](https://reader036.vdocuments.net/reader036/viewer/2022081606/5e19c7bda92af10936156d26/html5/thumbnails/7.jpg)
Differential by
Symptom Duration
Seconds Minutes Hours Days--Constant
Ischemic (TIA,Stroke)
BPPV**
Migraine
Vestibular
Neuritis
Demyelinating
Menieres
Mass lesion
Perilymphatic
fistula
SSCC dehiscence
**BPPV may be perceived as lasting hours-days
![Page 8: Vertigo - cdn.ymaws.com · Unidirectional Nystagmus . 44F vertigo, nausea & vomiting Impaired VOR Gain to the right . Vertigo • History • Anatomy/Physiology • Horses • Zebras](https://reader036.vdocuments.net/reader036/viewer/2022081606/5e19c7bda92af10936156d26/html5/thumbnails/8.jpg)
Peripheral vs. Central
![Page 9: Vertigo - cdn.ymaws.com · Unidirectional Nystagmus . 44F vertigo, nausea & vomiting Impaired VOR Gain to the right . Vertigo • History • Anatomy/Physiology • Horses • Zebras](https://reader036.vdocuments.net/reader036/viewer/2022081606/5e19c7bda92af10936156d26/html5/thumbnails/9.jpg)
Tonic firing from each peripheral
vestibular apparatus
Tonic firing from each
peripheral vestibular apparatus
Pathophysiology of vestibular symptoms and signs: The clinical examination,
DS Zee Neurology Continuum Aug 2006 pg 18
![Page 10: Vertigo - cdn.ymaws.com · Unidirectional Nystagmus . 44F vertigo, nausea & vomiting Impaired VOR Gain to the right . Vertigo • History • Anatomy/Physiology • Horses • Zebras](https://reader036.vdocuments.net/reader036/viewer/2022081606/5e19c7bda92af10936156d26/html5/thumbnails/10.jpg)
Tonic firing from each peripheral
vestibular apparatus
Asymmetry of the tonic firing tells
the brain there’s movement
Tonic firing from each
peripheral vestibular apparatus
![Page 11: Vertigo - cdn.ymaws.com · Unidirectional Nystagmus . 44F vertigo, nausea & vomiting Impaired VOR Gain to the right . Vertigo • History • Anatomy/Physiology • Horses • Zebras](https://reader036.vdocuments.net/reader036/viewer/2022081606/5e19c7bda92af10936156d26/html5/thumbnails/11.jpg)
Lesion or overaction
(BPPV) of the peripheral
vestibular aparatus or its
central connections
creates asymmetry of
tonic input and the
sensation of movement
![Page 12: Vertigo - cdn.ymaws.com · Unidirectional Nystagmus . 44F vertigo, nausea & vomiting Impaired VOR Gain to the right . Vertigo • History • Anatomy/Physiology • Horses • Zebras](https://reader036.vdocuments.net/reader036/viewer/2022081606/5e19c7bda92af10936156d26/html5/thumbnails/12.jpg)
BPPV
~3% population
• Vertigo lasts seconds to
minutes
• Provoked by head rotation
• Roll over in bed
• Look over shoulder
• Nausea/Vomiting
• Queasy for hours in
between
85-90%
![Page 13: Vertigo - cdn.ymaws.com · Unidirectional Nystagmus . 44F vertigo, nausea & vomiting Impaired VOR Gain to the right . Vertigo • History • Anatomy/Physiology • Horses • Zebras](https://reader036.vdocuments.net/reader036/viewer/2022081606/5e19c7bda92af10936156d26/html5/thumbnails/13.jpg)
Dix Hallpike
Semin Neurol. 2009;29(5):500-508.
![Page 14: Vertigo - cdn.ymaws.com · Unidirectional Nystagmus . 44F vertigo, nausea & vomiting Impaired VOR Gain to the right . Vertigo • History • Anatomy/Physiology • Horses • Zebras](https://reader036.vdocuments.net/reader036/viewer/2022081606/5e19c7bda92af10936156d26/html5/thumbnails/14.jpg)
Dix-
Hallpike
and Epley
(Steps 1-5)
Semin Neurol. 2009;29(5):500-508.
Diagnosis
and
treatment for
Right
Posterior
Canal BPPV
![Page 15: Vertigo - cdn.ymaws.com · Unidirectional Nystagmus . 44F vertigo, nausea & vomiting Impaired VOR Gain to the right . Vertigo • History • Anatomy/Physiology • Horses • Zebras](https://reader036.vdocuments.net/reader036/viewer/2022081606/5e19c7bda92af10936156d26/html5/thumbnails/15.jpg)
Epley
Video
![Page 16: Vertigo - cdn.ymaws.com · Unidirectional Nystagmus . 44F vertigo, nausea & vomiting Impaired VOR Gain to the right . Vertigo • History • Anatomy/Physiology • Horses • Zebras](https://reader036.vdocuments.net/reader036/viewer/2022081606/5e19c7bda92af10936156d26/html5/thumbnails/16.jpg)
Semont For Right posterior canal BPPV
Semin Neurol. 2009;29(5):500-508.
![Page 17: Vertigo - cdn.ymaws.com · Unidirectional Nystagmus . 44F vertigo, nausea & vomiting Impaired VOR Gain to the right . Vertigo • History • Anatomy/Physiology • Horses • Zebras](https://reader036.vdocuments.net/reader036/viewer/2022081606/5e19c7bda92af10936156d26/html5/thumbnails/17.jpg)
BPPV
• No central mimics of DH nystagmus
• Surgery
• Avoid chronic vestibular suppressants
![Page 18: Vertigo - cdn.ymaws.com · Unidirectional Nystagmus . 44F vertigo, nausea & vomiting Impaired VOR Gain to the right . Vertigo • History • Anatomy/Physiology • Horses • Zebras](https://reader036.vdocuments.net/reader036/viewer/2022081606/5e19c7bda92af10936156d26/html5/thumbnails/18.jpg)
Vestibular
Neuritis
• Unidirectional
nystagmus
• VOR Gain
• Steroids and
antivirals
VOR Gain Neurology 2011;76;e71
![Page 19: Vertigo - cdn.ymaws.com · Unidirectional Nystagmus . 44F vertigo, nausea & vomiting Impaired VOR Gain to the right . Vertigo • History • Anatomy/Physiology • Horses • Zebras](https://reader036.vdocuments.net/reader036/viewer/2022081606/5e19c7bda92af10936156d26/html5/thumbnails/19.jpg)
Vestibular Nystagmus
![Page 20: Vertigo - cdn.ymaws.com · Unidirectional Nystagmus . 44F vertigo, nausea & vomiting Impaired VOR Gain to the right . Vertigo • History • Anatomy/Physiology • Horses • Zebras](https://reader036.vdocuments.net/reader036/viewer/2022081606/5e19c7bda92af10936156d26/html5/thumbnails/20.jpg)
Vestibular neuritis
Slow Phase
![Page 21: Vertigo - cdn.ymaws.com · Unidirectional Nystagmus . 44F vertigo, nausea & vomiting Impaired VOR Gain to the right . Vertigo • History • Anatomy/Physiology • Horses • Zebras](https://reader036.vdocuments.net/reader036/viewer/2022081606/5e19c7bda92af10936156d26/html5/thumbnails/21.jpg)
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
![Page 22: Vertigo - cdn.ymaws.com · Unidirectional Nystagmus . 44F vertigo, nausea & vomiting Impaired VOR Gain to the right . Vertigo • History • Anatomy/Physiology • Horses • Zebras](https://reader036.vdocuments.net/reader036/viewer/2022081606/5e19c7bda92af10936156d26/html5/thumbnails/22.jpg)
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
![Page 23: Vertigo - cdn.ymaws.com · Unidirectional Nystagmus . 44F vertigo, nausea & vomiting Impaired VOR Gain to the right . Vertigo • History • Anatomy/Physiology • Horses • Zebras](https://reader036.vdocuments.net/reader036/viewer/2022081606/5e19c7bda92af10936156d26/html5/thumbnails/23.jpg)
MS
Diplopia
and
vertigo
![Page 24: Vertigo - cdn.ymaws.com · Unidirectional Nystagmus . 44F vertigo, nausea & vomiting Impaired VOR Gain to the right . Vertigo • History • Anatomy/Physiology • Horses • Zebras](https://reader036.vdocuments.net/reader036/viewer/2022081606/5e19c7bda92af10936156d26/html5/thumbnails/24.jpg)
Lung
adenocarcinoma
metastasis
![Page 25: Vertigo - cdn.ymaws.com · Unidirectional Nystagmus . 44F vertigo, nausea & vomiting Impaired VOR Gain to the right . Vertigo • History • Anatomy/Physiology • Horses • Zebras](https://reader036.vdocuments.net/reader036/viewer/2022081606/5e19c7bda92af10936156d26/html5/thumbnails/25.jpg)
Visually mediated dizziness
Post concussive
Migraine
Prior vertigo
![Page 26: Vertigo - cdn.ymaws.com · Unidirectional Nystagmus . 44F vertigo, nausea & vomiting Impaired VOR Gain to the right . Vertigo • History • Anatomy/Physiology • Horses • Zebras](https://reader036.vdocuments.net/reader036/viewer/2022081606/5e19c7bda92af10936156d26/html5/thumbnails/26.jpg)
Vestibular Schanomma
![Page 27: Vertigo - cdn.ymaws.com · Unidirectional Nystagmus . 44F vertigo, nausea & vomiting Impaired VOR Gain to the right . Vertigo • History • Anatomy/Physiology • Horses • Zebras](https://reader036.vdocuments.net/reader036/viewer/2022081606/5e19c7bda92af10936156d26/html5/thumbnails/27.jpg)
Superior semicircular canal
dehiscence Valsalva induced vertigo
![Page 28: Vertigo - cdn.ymaws.com · Unidirectional Nystagmus . 44F vertigo, nausea & vomiting Impaired VOR Gain to the right . Vertigo • History • Anatomy/Physiology • Horses • Zebras](https://reader036.vdocuments.net/reader036/viewer/2022081606/5e19c7bda92af10936156d26/html5/thumbnails/28.jpg)
Perilymphatic fistula
NEJM 366;4
Perilymphatic fistula Test
Can also see Tulio phenomenon
![Page 29: Vertigo - cdn.ymaws.com · Unidirectional Nystagmus . 44F vertigo, nausea & vomiting Impaired VOR Gain to the right . Vertigo • History • Anatomy/Physiology • Horses • Zebras](https://reader036.vdocuments.net/reader036/viewer/2022081606/5e19c7bda92af10936156d26/html5/thumbnails/29.jpg)
Vertebral artery
dissection and
cerebellar infarct
![Page 30: Vertigo - cdn.ymaws.com · Unidirectional Nystagmus . 44F vertigo, nausea & vomiting Impaired VOR Gain to the right . Vertigo • History • Anatomy/Physiology • Horses • Zebras](https://reader036.vdocuments.net/reader036/viewer/2022081606/5e19c7bda92af10936156d26/html5/thumbnails/30.jpg)
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
![Page 31: Vertigo - cdn.ymaws.com · Unidirectional Nystagmus . 44F vertigo, nausea & vomiting Impaired VOR Gain to the right . Vertigo • History • Anatomy/Physiology • Horses • Zebras](https://reader036.vdocuments.net/reader036/viewer/2022081606/5e19c7bda92af10936156d26/html5/thumbnails/31.jpg)
Bilateral Vestibular Loss
• CANVAS
• Cerebellar ataxia
• Neuropathy
• Vestibular areflexia
![Page 32: Vertigo - cdn.ymaws.com · Unidirectional Nystagmus . 44F vertigo, nausea & vomiting Impaired VOR Gain to the right . Vertigo • History • Anatomy/Physiology • Horses • Zebras](https://reader036.vdocuments.net/reader036/viewer/2022081606/5e19c7bda92af10936156d26/html5/thumbnails/32.jpg)
Visual dizziness
![Page 33: Vertigo - cdn.ymaws.com · Unidirectional Nystagmus . 44F vertigo, nausea & vomiting Impaired VOR Gain to the right . Vertigo • History • Anatomy/Physiology • Horses • Zebras](https://reader036.vdocuments.net/reader036/viewer/2022081606/5e19c7bda92af10936156d26/html5/thumbnails/33.jpg)
Tardive dizziness following
lesion to Mollaret’s Triangle Red
Nucleus
Inferior
Olive
Dentate
![Page 34: Vertigo - cdn.ymaws.com · Unidirectional Nystagmus . 44F vertigo, nausea & vomiting Impaired VOR Gain to the right . Vertigo • History • Anatomy/Physiology • Horses • Zebras](https://reader036.vdocuments.net/reader036/viewer/2022081606/5e19c7bda92af10936156d26/html5/thumbnails/34.jpg)
Distinguishing central from peripheral
![Page 35: Vertigo - cdn.ymaws.com · Unidirectional Nystagmus . 44F vertigo, nausea & vomiting Impaired VOR Gain to the right . Vertigo • History • Anatomy/Physiology • Horses • Zebras](https://reader036.vdocuments.net/reader036/viewer/2022081606/5e19c7bda92af10936156d26/html5/thumbnails/35.jpg)
Peripheral
– Head impulse test: Abnormal
– Unidirectional nystagmus
– No vertical misalignment
Central
– Head Impulse test: Normal
– Alternating nystgmus
– Skew deviation
Skew video
![Page 36: Vertigo - cdn.ymaws.com · Unidirectional Nystagmus . 44F vertigo, nausea & vomiting Impaired VOR Gain to the right . Vertigo • History • Anatomy/Physiology • Horses • Zebras](https://reader036.vdocuments.net/reader036/viewer/2022081606/5e19c7bda92af10936156d26/html5/thumbnails/36.jpg)
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
![Page 37: Vertigo - cdn.ymaws.com · Unidirectional Nystagmus . 44F vertigo, nausea & vomiting Impaired VOR Gain to the right . Vertigo • History • Anatomy/Physiology • Horses • Zebras](https://reader036.vdocuments.net/reader036/viewer/2022081606/5e19c7bda92af10936156d26/html5/thumbnails/37.jpg)
Questions