Vertigo
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? • • • • • • • • • 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 • 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 • A feeling of unsteadiness or insecurity without rotation. Standing and walking are difficult. Common in parkinsonism and in diabetic polyneuropathy. 3. Light headedness • Swimming, floating, giddy or swaying sensation in the head or in the room. Characteristic of psychiatric patients (anxiety, depression, hyperventilation sy). 4. Presyncope • 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 • • • • • • • 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 • • • 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 • • • • 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 • • • • • • • • 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 • • • • • • • • 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 a) Presyncope • • • b) Cardiac arrhythmias Vasovagal syncope Orthostatic dysregulation Dysequilibrium • • c) Parkinson sy Diabetic neuropathy Light-headedness • • 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 • • • • • • 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 • • • • 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 • • • • 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 • • • • • • • • • 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 • • • • 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
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