Evaluation and Management of Dizziness and Vertigo

Peripheral vestibulopathy

Anatomy of Anatomy of Vestibulo-Cochlear SystemVestibulo-Cochlear System

Maintenance of balanceMaintenance of balance Higher centersHigher centers : :

* Extra pyramidal system* Extra pyramidal system* Cerebellum* Cerebellum* Reticular formation* Reticular formation

Brain stem

integrating center

(Vestibular nuclei)

(Sensory systems)

Vision

Proprioception

Vestibular

labyrinths

( Effector pathways )

Oculomotor system

(Vestibulo-ocular reflex)

Antigravity muscles controlling posture & gait (Vestibulo spinal reflex)

Perception of orientation(in Vestibular cortex)

VertigoVertigo

Illusion of movement of the patient or patient ‘s surrounIllusion of movement of the patient or patient ‘s surroundingsdings

May be described as – rotatory, spinning, tilting or swayMay be described as – rotatory, spinning, tilting or swayinging

Accompanying symptoms-Accompanying symptoms- nausea, vomiting, diaphoresis, apprehensionnausea, vomiting, diaphoresis, apprehension DisequilibriumDisequilibrium nystagmus.nystagmus.

Disturbance in the peripheral or central nervous systemDisturbance in the peripheral or central nervous system

DizzinessDizziness

An ambiguous term that patients use to describe An ambiguous term that patients use to describe several entirely different subjective states. several entirely different subjective states.

The complaint of dizziness generally can be The complaint of dizziness generally can be divided into 1 of 4 categories-divided into 1 of 4 categories-

1. Vertigo1. Vertigo 2. Syncope or presyncope2. Syncope or presyncope 33. . DisequilibriumDisequilibrium

44. . Ill-defined dizzinessIll-defined dizziness

SyncopeSyncope Sense of impending loss of consciousness or fainting. (When tSense of impending loss of consciousness or fainting. (When t

he cerebral perfusion falls below the level required to maintain he cerebral perfusion falls below the level required to maintain OO2 2 and glucose to the brain)and glucose to the brain)

Causes:Causes: Cardiac – Cardiac – VasovagalVasovagal

Arrhythmias Arrhythmias Obstructive Obstructive Carotid sinus syndrome Carotid sinus syndrome

Orthostatic hypotension- Orthostatic hypotension- Drug inducedDrug induced Volume depleted Volume depleted Autonomic insufficiency Autonomic insufficiency

DisequilibriumDisequilibrium

Sense of imbalance, unsteadiness or drunkenness without vertigo.Sense of imbalance, unsteadiness or drunkenness without vertigo.

Mismatch of inputs from systems subserving spatial orientation e.Mismatch of inputs from systems subserving spatial orientation e.g. vestibular, proprioceptive, cerebeller, visual or extra pyramidal g. vestibular, proprioceptive, cerebeller, visual or extra pyramidal systems.systems.

CausesCauses :: Multiple sensory deficitsMultiple sensory deficits Cerebeller dysfunction Cerebeller dysfunction Non-functioning labyrinths Non-functioning labyrinths Extra pyramidal disorders Extra pyramidal disorders Post. fossa tumour Post. fossa tumour Drug intoxication Drug intoxication

Ill-defined dizziness :Ill-defined dizziness :(Other than vertigo, syncope, or (Other than vertigo, syncope, or disequilibrium)disequilibrium)

Usually a vague light- headedness, giddiness Usually a vague light- headedness, giddiness or fear of falling.or fear of falling.

Causes:Causes:

Hyperventilation syndromeHyperventilation syndrome

Anxiety neurosisAnxiety neurosis

Hysterical neurosisHysterical neurosis

Affective disordersAffective disorders

DepressionDepression

VertigoVertigo Causes :Causes :

Peripheral Peripheral - Physiologic (motion sickne- Physiologic (motion sickness)ss)

- Vestibular neuronitis- Vestibular neuronitis- Benign positional vertigo- Benign positional vertigo- Menieres disease- Menieres disease- Post-traumatic vertigo- Post-traumatic vertigo- Labyrinthine imbalance- Labyrinthine imbalance

Central Central - Brain-stem ischemia- Brain-stem ischemia- Multiple sclerosis- Multiple sclerosis- Post. Fossa tumour- Post. Fossa tumour- Basilar migraine- Basilar migraine

Types of dizziness and vertigo

Sensation of motion (vertigo): central or peripheral? Sensation of black-out (near-syncope): hypoperfusion (hypotension or cardiac origin) Disequilibrium: with one of multiple sensory deficits (visual, propioceptive, cerebellar…) Ill-defined (head discomfort): mild headache, anxiety, depression or hyperventilation syndrome

Dizziness

1. Black-out: hypoperfusion (hypotension or cardiac origin)

2. Disequilibrium: Some sensory deficits3. Head discomfort: mild headache, anxiety,

depression or hyperventilation syndrome

＊Watch for unsteady gait＊ Dizziness is more complicated

Black-out (near syncope)

Postural hypotension [autonomic dysfunction

( esp. DM ), drug-induced, elderly, debilitated

or volume depletion]

Anemia

Cardiac arrhythmia

Obstructive (aortic or carotid stenosis)

Vasovagal syncope

Vertebro-basilar insufficiency (VBI)

Subclavian steal syndrome

D/D of vertigo

The ‘‘identification of central or serious vertigo’’ was voted as the top priority for clinical decision rule development in adults

The CT is not good enough; The MRI is not available right now.

The most effective way to ‘‘rule-out’’ a central disorder is to ‘‘rule-in’’ a specific peripheral vestibular disorder.

Peripheral vestibulopathy

Vestibular neuronitis

Benign paroxysmal positional vertigo (BPPV)

Meniere’s disease

Post-traumatic vertigo

Viral or bact. labyrinthitis

Acoustic neuroma

Motion sickness

Vestibular neuritis The most common cause of acute severe vertigo. It is caused by a viral lesion of the eighth cranial nerve. Vertigo is accompanied by severe nausea, vomiting, and i

mbalance. Typically hearing is not affected, but if severe vertigo is ac

companied by hearing loss then the most common cause is labyrinthitis—also of a presumed viral etiology.

The hallmark examination signs of vestibular neuritis are a spontaneous unidirectional horizontal nystagmus.

Patients with vestibular neuritis are typically debilitated for the first day.

The natural history of the disorder is a gradual recovery over weeks to months.

Meniere’s disease

Meniere’s disease patients are probably less likely to present to the emergency department during acute attacks compared with those with acute severe vertigo.

The reason may be that Meniere’s disease attacks are typically limited to a few hours, and patients learn over time that the attacks resolve with rest.

Unilateral hearing loss, which is typically a fluctuating symptom early in the course, but then becomes a fixed and progressive feature.

Unilateral tinnitus (typically a low roaring sound rather than a high pitched sound) or bothersome pressure in one ear

Benign paroxysmal positional vertigo

The episodes are triggered by head movements, not simply worsened by head movements.

It is important to know that dizziness of any cause can worsen after certain position changes.

The patient with constant vertigo who reports that the symptom is better in a certain position and worse with movement should be classified as having acute severe vertigo rather than BPPV

The vertigo attacks last less than one minute, followed by a return to normal.

Some patients have dizziness between paroxysmal positional vertigo

Central Vestibulopathy

Brainstem stroke or lesion

Cerebellar infarct, hemorrhage or tumor

Drug-induced ( phenytoin overdose, Tegretol intolerance, aminoglycoside etc… )

Lobes: flocculonodLobes: flocculonodular, anterior, posterular, anterior, posterior has tonsilsior has tonsils

Vertical division – Vertical division – vermis (midline) pavermis (midline) paravermis, lateral heravermis, lateral hemispheresmispheres

Both divisions correBoth divisions correspond to vestibulo- spond to vestibulo- (arche), spino- (pale(arche), spino- (paleo) , ponto- (neo) ereo) , ponto- (neo) erebellumbellum

Coordination

Arm bounce：請病人手臂平舉，檢查者施予一股向下的力量，當力量消失時，病人手臂呈現上下擺動的現象。

Finger-nose test: dysmetria, intentional tremorHeel-knee-shin test: cerebellar or sensory ataxiaPast pointing: 將檢查者的手指固定在一處 , 請病人舉臂過頭，再

將它放下來碰觸檢查者的手指。重複數次之後，請病人閉上眼睛再試 . 若重複且固定的偏向一側 (lesion side) ，就稱為 past pointing 。(cerebellar and vestibular lesions 皆會發生， cerebellar 為單手偏向病側 ， vestibular 為雙手偏向病側 )

Rapid alternating movement: 請病人用手心拍大腿，然後翻面，再用手背拍同一個地方，盡可能快速的重複這個動作 (Dysdiadochokinesia)

Coordination

Romberg testRomberg test 睜眼和閉眼都搖晃睜眼和閉眼都搖晃 cerebellar deficit (cerebellar cerebellar deficit (cerebellar

ataxia)ataxia)睜眼正常，閉眼搖晃 睜眼正常，閉眼搖晃 (positive Romberg’s sign) (positive Romberg’s sign) proproprioceptive deficit (sensory ataxia)prioceptive deficit (sensory ataxia)

Tandem gait:Tandem gait:

History taking

l.Ear Problem: ear pain or fullness sensation, tinnitus l.Ear Problem: ear pain or fullness sensation, tinnitus (unilateral), hearing impairment.(unilateral), hearing impairment.

2.Cardiovascular Problem: arrhythmia, orthostatic hy2.Cardiovascular Problem: arrhythmia, orthostatic hypotension.potension.

3.Diplopia, dysphagia, dysarthria, drop attack, numb3.Diplopia, dysphagia, dysarthria, drop attack, numbness or weakness of the face or body.ness or weakness of the face or body.

4.Drug history.4.Drug history.

Neurological examination

l. Nystagmus: gaze-evoked, positional (and positionil. Nystagmus: gaze-evoked, positional (and positioning). ng).

2. Cranial nerve lesion and brainstem sign.2. Cranial nerve lesion and brainstem sign.

3. Cerebellar sign.3. Cerebellar sign.

4. Any long tract sign.4. Any long tract sign.

Characteristics of nystagmus

Unidirectional or multidirectional ? Unidirectional or multidirectional ?

Horizontal, rotary(torsional) or vertical?Horizontal, rotary(torsional) or vertical?

More severe than vertigo? (central)More severe than vertigo? (central)

Milder than vertigo? (peripheral) : due to visual inMilder than vertigo? (peripheral) : due to visual inhibitionhibition

Duration? latent? fatique?Duration? latent? fatique? (Dix-Hallpike maneuve (Dix-Hallpike maneuver for positional nystagmus)r for positional nystagmus)

SEMINARS IN NEUROLOGY/VOLUME 29, NUMBER 5 2009

BPPVBPPV

Benign Paroxysmal Positional VBenign Paroxysmal Positional Vertigo(BPPV)ertigo(BPPV)

Most commonMost common Precipitated by movement or position change in the hPrecipitated by movement or position change in the h

ead or bodyead or body Lasts only a few secondsLasts only a few seconds Aetiology: Aetiology:

• Head traumaHead trauma• StapedectomyStapedectomy• Intoxication – alcohol , barbituratesIntoxication – alcohol , barbiturates• Canelithiasis – most commonCanelithiasis – most common

Course – variable Course – variable • subsides spontaneously in weekssubsides spontaneously in weeks• recurs months or years laterrecurs months or years later

Otolithic membrane of the macula showing thOtolithic membrane of the macula showing the organization of calcium carbonate otolithse organization of calcium carbonate otoliths

ANATOMY & PHYSIOLOGY

BPPV by canal type

Posterior Posterior HorizontalHorizontal AnteriorAnterior

Estimated Estimated frequencyfrequency

81-89%81-89% 8-17%8-17% 1-3%1-3%

Provocative Provocative maneuvermaneuver

Dix HallpikeDix Hallpike Supine Roll Test Supine Roll Test ((Pagnini-McClure)Pagnini-McClure)

Dix HallpikeDix Hallpike

NystagmusNystagmus Upbeat, torsionaUpbeat, torsional l

HorizontalHorizontal Direction ChangingDirection Changing

Downbeat, torsiDownbeat, torsionalonal

Dix–Hallpike positioning maneuverDix–Hallpike positioning maneuver

Supine head turn maneuverSupine head turn maneuver

Canalith repositioning maneuver (EpCanalith repositioning maneuver (Epley maneuver)ley maneuver)

Semont liberatory maneuverSemont liberatory maneuver

Lempert 360- (Barbeque) degree roll Lempert 360- (Barbeque) degree roll maneuvermaneuver

Forced prolonged position maneuver

即側躺眼振較弱側即側躺眼振較弱側 (( 健側健側 )12)12 小小時 時

Treatment

1. Antihistamine: Vena IM or IV, meclizine,1. Antihistamine: Vena IM or IV, meclizine,

merislon etc…merislon etc…

2. Anticholinergic: Artane, akineton. 2. Anticholinergic: Artane, akineton.

3. Phenothiazine: Novamin, primperan.3. Phenothiazine: Novamin, primperan.

4. Sympathomimetic: Amphetamine, ephedrine.4. Sympathomimetic: Amphetamine, ephedrine.

5. Benzodiazepine:5. Benzodiazepine:

6. Circulation improver: Diphadol, sanyl, suzin (sibe6. Circulation improver: Diphadol, sanyl, suzin (sibelium), perdipine etc...lium), perdipine etc...

7. Other: Dogmatyl, wintermin7. Other: Dogmatyl, wintermin

Case 1Case 1

68 y/o female68 y/o female DizzinessDizziness Nausea and vomitingNausea and vomiting 99/8/499/8/4

Case 2Case 2

50y/o female50y/o female Dizziness Dizziness Revisit ER againRevisit ER again Vertical nystagmusVertical nystagmus 99/7/2699/7/26

Case 3Case 3

56 y/o female56 y/o female DizzinessDizziness Lt hand dysmetriaLt hand dysmetria 99/9/399/9/3

Case 4Case 4

80y/o female80y/o female Falling down accidentFalling down accident DizzinessDizziness Mild nausea sensationMild nausea sensation 100/4/3100/4/3