Vertigo
Maria Tünde Magyar
Dizziness
• Vestibular
• Proprioception
• Optic input (afferentation) carries not
synchronizated information to the CNS,
but contradictory to each other. (Büki)
What could be reffered to as
„dizziness” by the patient?
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Rotational vertigo
Sense of instability
Ataxia of gait
Disturbance of vision
Loss of contact with surroundings
Nausea
Loss of memory
Loss of confidence
Epileptic convulsion
What should be considered dizziness
by medical personnel?
1. Vertigo
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A sense of feeling the environment moving when it does not. Mostly
rotational movement. Persists in all positions. Aggravated by head
movement. Typical of vestibular lesion.
2. Dysequilibrium/imbalance
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A feeling of unsteadiness or insecurity without rotation. Standing
and walking are difficult. Common in parkinsonism and in diabetic
polyneuropathy.
3. Light headedness
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Swimming, floating, giddy or swaying sensation in the head or in
the room. Characteristic of psychiatric patients (anxiety,
depression, hyperventilation sy).
4. Presyncope
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General weakness, pale face, sweating (orthostatic hypotension)
Epidemiology
• Dizziness (including vertigo and nonvestibular
dizziness) is among the most common
complaints in medicine, affecting approximately
20-30 % of the population
• Prevalence of vertigo is 4.9%, incidence 1.4%
• Male: female=1:2.7
• Prevalence increases with age, it is more
common in elderly
Curr Opin Neurol 2007;20:40-46.
Development of vertigo
Afferent
Visual
Proprioceptive
Vestibular
CNS
Dizziness
Efferent
Oculomotor
Sceletal muscles
Vegetative
Questions to be asked (taking the
history)
Anamnesis
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What the patient means by vertigo
Time of onset
Temporal pattern
Associated sings and symptoms (tinnitus,
hearing loss, headache, double vision,
numbness, difficulty of swallowing)
Precipitating, aggravating and relieving factors
Loss of consciousness
If episodic: sequence of events, activity at
onset, aura, severity, amnesia etc.
Examination of the patient with
vertigo
Physical examination
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BP, HR, Schellong test
Spontaneous nystagmus
Positional nystagmus
Schellong test
• After 10 min supine position, the subject is
required to stand for 10-20 min, during
which time the BP is measured
continuously;
• A fall of systolic pressure of 20 mm Hg or
more and/or decreasing of diastolic BP
more than 10 mmHg indicates orthostatic
hypotension.
Cardiac arrhythmias, ↓↑
BP, orthostatic hypotension
Spontaneous nystagmus
• Fast and slow component
• Direction of nystagmus is described
according to fast movement
• Horizontal, vertical, rotatory
• Intensity:
– I. degree: when present only on deviation of the eyes
– II. degree: when also present looking straight forward
– III. degree: when visible even on gaze in the direction
opposite to the fast beat
Posture and balance control
• Romberg’s test
• Blind walking, Untenberger
• Bárány’s test
Stimulations of labyrinth
• Caloric test (cold, warm water)
• Rotational test
Examination of the patient with
vertigo
Laboratory examinations and imaging
• Electronystagmography
• Video-oculography
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Audiometry
BAEP
CT
MRI
In case of vertigo
No sponteous nystagmus
Sponteous nystagmus
Posture and balance control negative
Posture and balance control positive
Nausea
vomiting
Sweating, tachycardia
GI disorder Chest pain
Internal
medicine
Anxiety
Angina, MI
Cardiology
Psychiatry
Nausea, vomiting, sweating, anxiety
„Harmonic”
vestibular sy
„Dysharmonic”
vestibular sy
Loss of hearing,
tinnitus
Numbness,
double vision,
dysarthria
Vestibular
neuronitis,
Meniére disease
Brainstem infarct
Otology
Neurology
peripheral
central
Nystagmus
horizontal, unidirectional
vertical nystagmus implies
central lesion, direction of
horizontal nystagmus can
change with the direction of
gaze
Nystagmus latency
latency before onset,
transient, <1 min
no latency; or persistent
>1 min
Vertigo
severe, often rotational
mild
Nausea, vomiting
usually present
usually absent
Hearing loss, tinnitus
frequently present
absent
Cranial nerve or brainstem
signs
absent
often present
Tendency to fall
to the side opposite the
nystagmus
to the side of nystagmus
Common causes of vertigo
Peripheral
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Benign paroxysmal positional vertigo
(18.3%)
Vestibular neuronitis (7.9%)
Labyrinthitis
Meniére disease (7.8%)
Vestibular paroxysmia (2,9%)
Posttraumatic
Perilymph fistula (0,4%)
Toxins, medications
Common causes of vertigo
Central
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Brainstem TIA/infarct
Posterior fossa tumors
Multiple sclerosis
Cerebellar stroke
Syringobulbia
Arnold - Chiari deformity
Temporal lobe epilepsy
Vestibular/basilar migraine
Common causes of dizziness
Other
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Presyncope
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b)
Cardiac arrhythmias
Vasovagal syncope
Orthostatic dysregulation
Dysequilibrium
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c)
Parkinson sy
Diabetic neuropathy
Light-headedness
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Hyperventilation sy
Anxiety
Common causes of dizziness
Other
– Metabolic reasons
• Hypoglycemia
• Disturbances of electrolite homeostasis
(hypercalcemia, hyponatremia)
– Anemia
– Intoxication
• Alcohol
• Medications, drugs
• Toxins
Benign paroxysmal positional vertigo
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Most often
Lasts less than 30 seconds
Occurs only with a change in head position
Nystagmus is transient, fatigable and its direction is
constant
Reason: otoconia
Positional vertigo is not always benign and not
always vestibular in origin!
Vestibular neuronitis
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Common in spring and early summer
Sudden severe vertigo
„harmonic” vestibular syndrome
No cochlear symptoms (tinnitus, hearing
loss)
• Reduced caloric reaction on affected side
• Recurrent attacks
• Lasts for several days
Vestibular neuronitis
Reason: viral infection
Therapy:
1-3. days. bedrest, vestibular suppressants (diazepam,
clonazepam) antiemetics, vitamin B
antiviral agents (?), corticosteriods(?)
From 3. day: position training
Labyrinthitis, neurolabyrinthitis
As vestibular neuronitis, but there are also cochlear
symptoms.
Menière disease
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Menière 1861: „glaucoma of the inner ear”
Prevalence: 43/100000
Male:female=1:1.3
Very strong familial trend for Menière
disease is showed, up to 20% of family
members have similar symptoms
• In early stage unilateral, about 35% of the
cases become bilateral after 10 years
Menière disease
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Recurrent, spontaneous episodic vertigo
Vertigo lasts for at least 20 min
Horisontorotatory nystagmus always present
Severe vegetative signs (nausea, vomiting,
sweating)
Sense of pressure in the ear
Distorsion of sounds
Sensitivity to noises
Tinnitus
Progressive hearing loss, unilateral first
Lancet 2008:372:406-14
Vestibular paroxysmia
• Short attacks of rotational vertigo lasting
seconds to minutes
• Attacks frequently dependent on particular head
positions
• Hypacusis, tinnitus permanently or during the
attacks
• Measurable auditory or vestibular deficits by
neurophysiological methods
• Carbamazepine effective
• Reason: neurovascular compression of VIIIth
cranial nerve
Neurology 2008:71:1006-14
Oto- or vestibulotoxicity
• Cytostatics: vincristine, cisplatin
• Antibiotics: gentamycin, streptomycin,
netilmycin, tobramycin, vancomycin
• Furosemide
• Sulfonamide
• Quinins
• Aspirin, NSAID-s
• CO, Hg
Temporal epilepsy
• short, severe rotational postural vertigo
• sensory partial epileptic seizure
• rare
Vestibular migraine
• precipitated by irregular sleep, alcohol
intake, certain foods
• before the episodic occipital headache
(migraine)
• recurrent attacks of vertigo, ataxia,
diplopia, nystagmus
• lasts for minutes to hours
• more common in females
• familiar pattern - migraine
Other causes of vertigo
1. Kinetosis
2. Cervical spondylosis
3. Sensory deprivation (neuropathy, visual
impairment)
4. Anemia
5. Hypoglycaemia
6. Orthostatic hypotension
7. Hyperventilation
Kinetosis (motion sickness)
• physiological overstimulation
• mainly vegetative symptoms: nausea,
vomiting, pale face, bradycardia, sweating,
precollapsus
• visual fixation can help
• antihistamins: dimenhydramine,
promethazine
Cervical spondylosis, cervical vertigo
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Is still controversial
Somatosensory vertigo
C1/2, C6/7 spondylarthrosis
Disturbed proprioception causes postural
imbalance
• Neck pain, ataxia, gait imbalance,
nystagmus after neck turning
Orthostatic hypotension
• Orthostatic (postural) hypotension is an excessive fall in BP
when an upright position is assumed. The consensus
definition is a drop of > 20 mm Hg systolic, 10 mm Hg
diastolic, or both.
• Symptoms of faintness, dizziness, confusion, or blurred vision
occur within seconds to a few minutes of standing and resolve
rapidly on lying down.
• Reasons:
– hypovolemia
– medication side effects
– prolonged bed rest
– adrenal insufficiency
– autonomic dysfunction (multisystemic atrophy)
Hyperventilation
• common in panic attack
• anxiety
• hyperventilation, tachycardia, lightheadedness
• relative hypocalcemia, carpopedal
spasmus
• anxiolytics, breathing in plastic bag