Enis Alpin Guneri MD MSc RATIONAL APPROACH 1. Vertigo ? 1. Vertigo ? 2. Peripheral / Central ? 1. Vertigo ? 2. Peripheral / Central ? 3. Differential diagnosis 1. Vertigo ? 2. Peripheral / Central ? 3. Differential diagnosis 4. Treatment VERTIGO Illusion of motion • Rotation of the environment or self • Sway to sides or back and forth VERTIGO Asymmetrical activity (vestibular input comming form the labyrinths) between both vestibular nuclei or their central integration ETIOLOGY BPPV Vestibular migraine Ménière Vestibular neuronitis Central disorders Phobic postural vertigo Bilateral vestibulopathy Psychiatric VERTIGO PERIPHERAL • Vestibular labyrinth • VIII. nerve VERTIGO PERIPHERAL • Vestibular labyrinth • VIII. nerve CENTRAL • Vestibular nuclei • Brainstem • Cerebellum VERTIGO PERIPHERAL • • • • • BPPV Ménière VN/labyrinthitis Trauma Drugs (AG) 50% 25% 10% VERTIGO PERIPHERAL • • • • • BPPV Ménière VN/labyrinthitis Trauma Drugs (AG) CENTRAL 50% 25% 10% • Vascular 50 % • Demyelinating • Drugs (Alcohol, hypnotics, anticonvulsants) Peripheral or Central ? PERIPHERAL Onset Sudden CENTRAL Slow, Progressive PERIPHERAL CENTRAL Onset Sudden Slow, Progressive Intensity Severe Poorly described PERIPHERAL CENTRAL Onset Sudden Slow, Progressive Intensity Severe Poorly described Duration Paroxysmal Continuous PERIPHERAL CENTRAL Onset Sudden Slow, Progressive Intensity Severe Poorly described Duration Paroxysmal Continuous Nausea/Sweating + Ø PERIPHERAL CENTRAL Onset Sudden Slow, Progressive Intensity Severe Poorly described Duration Paroxysmal Continuous Nausea/Sweating + Ø CNS sign Ø + PERIPHERAL CENTRAL Onset Sudden Slow, Progressive Intensity Severe Poorly described Duration Paroxysmal Continuous Nausea/Sweating + Ø CNS sign Ø + Tinnitus/Hearing loss  Ø PERIPHERAL CENTRAL Onset Sudden Slow, Progressive Intensity Severe Poorly described Duration Paroxysmal Continuous Nausea/Sweating + Ø CNS sign Ø + Tinnitus/Hearing loss  Ø Nystagmus pattern Hor+Tor Vertical Conjugated Dissociated Fatiguable Nonfatiguable PERIPHERAL or CENTRAL ? Kattah, Stroke, 2009 Head Impulse Test, Skew Deviation Sensitivity: 100%, Spesificity: 96% Sensitivity is higher than MRG PERIPHERAL VERTIGO 1. BPPV 2. Ménière 3. Vestibular neuronitis 4. Labyrinthitis 5. Trauma 6. Perilymph fistula 7. SCC dehissence syndrome 8. Recurrent vestibulopathy 9. Delayed Endolymphatic Hydrops 10. Cogan syndrome 11. Toxic (Alcohol, Drugs) Differential diagnosis VERTIGO DX PROTOCOL 1. 2. 3. 4. 5. 6. 7. 8. 9. History ENT exam (endoscopy- microscopy) Otoneurological exam Positional tests Tuning fork tests/PTA/Speech Audiometry Acoustic immitansmetry/OAE/ABR/EcoG Caloric test ENG/VNG VEMP HISTORY is the most important step HISTORY 1. Duration 2. Triggers 3. Type of vertigo Duration of vertigo Seconds : BPPV Minutes : V. Paroxysmia (vascular ring) Perylimph fistula/SSCDS (<1 min) Hours : Ménière (20 min-24 hrs) V. Migraine Days : V. Neuronitis/Labyrinthitis EXAMINING EYE MOVEMENTS NORMAL SACCADES ABNORMAL SACCADES R hypermetric R hypometric SMOOTH PURSUIT SMOOTH PURSUIT Saccadic SP Skew deviation Skew deviation Alternate cover test Ocular tilt reaction OCULAR TILT REACTION 1- Skew Deviation 2- Head Tilt 3- Ocular Torsion Normal head and eye posture Ocular tilt reaction Normal head and eye posture Leftward ocular tilt Ocular tilt reaction Central Peripheral NYSTAGMUS NYSTAGMUS Only objective sign Slow and Fast phases Direction of the fast phase FUNDOSCOPY Movements of the optic disc and retinal vessles Opposite to the direction of the nystagmus Upward movements in downbeating nystagmus INDUCED NYSTAGMUS 1. Gaze evoked 2. Optokinetic 3. Rotational 4. Head shaking 5. Caloric 6. Positional 7. Hyperventilation 8. Vibration NYSTAGMUS EVALUATION WITH THE GOOGLES 1. 2. 3. 4. 5. 6. 7. Spontaneous Gaze-evoked Head-shaking Positioning Positional Caloric Hyperventilation induced OPTIC FIXATION Supression of the nystagmus with visual fixation Nonsupression: central smooth pursuit defect (commonly cerebellar) Horizontal nystagmus Typical peripheral Horizontal torsional Stimulation of all three channels in the right side + + Lesion: Labyrinth or Vestibular nuclei Horizontal nystagmus Horizontal canal BPPV: Positional horizontal nystagmus Pure Horizontal Horizontal nystagmus Gaze evoked Horizontal nystagmus Lesion: n. Praepositus Hypoglossi Pure Horizontal Torsional nystagmus Dissociated nystagmus Downbeat nystagmus Downbeat nystagmus Craniocervical anomalies (Arnold Chiari) Cerebellar degeneration, tumors, drugs, Downbeat nystagmus Superior canal BPPV See saw nystagmus central pathologies parasellar masses, stroke, syringobulbia albinism retinitis pigmentosa Upbeat nystagmus Brain stem tm or infarction MS Wernicke’s encephalopathy Drug intoxications BEDSIDE TESTS 1. Head Shaking Nystagmus 2. Head Impulse(Halmagy/Curthoys) Test 3. Positional tests Head shaking nystagmus HEAD IMPULSE TEST HALMAGYI CURTHOYS HEAD IMPULSE TEST Fast 300horizontal head movements (thrust) Intact VOR: symmetry (-) Head Impulse Test HEAD IMPULSE TEST Correcting (catch up) saccade Unilateral labyrinthine loss HEAD IMPULSE TEST Absent VOR (asymmetry) (+) Head Impulse Test 95% spesific No need to Calorics if its (+) HEAD IMPULSE TEST Correcting (catch up) saccade Bilateral labyrinthine loss HEAD IMPULSE TEST Acute onset nystagmus Normal (-) Head Impulse Test indicates a CENTRAL LESION POSITIONAL TESTS DIX HALLPIKE TEST Roll test Superior Canal Test Vertical head down test Torsional components Cancel each other Downbeating nystagmus POSITIONAL NYSTAGMUS QUIX TEST (Past Pointing) CEREBELLAR TESTS Romberg Test Tandem Romberg Positive Romberg Test Fromberg Testi Unterberger (Fukuda) Test Fistula Test Pressure (positive or negative) induced nystagmus Valsalva’s manoeuvre Politzer balloon Tympanometry Tragal compression Perilymph fistula Canal dehiscence syndrome BITHERMAL CALORIC TEST AUDIOLOGICAL Pure Tones SDS Acoustic immitansmetry OAE ECoG ABR AUDIOGRAM FREQUENCY INTENSITY NORMAL [ o [ o [ o [ o [ o [ o CONDUCTIVE HEARING LOSS [ o [ o [ o [ o [ o o SENSORINEURAL HEARING LOSS [ o [ o [ o [ o [ o o MIXED LOSS [ [ [ [ [ o o o o o o ENG Corneoretinal pts Eyeblink artefacts EMG activity Unstable baseline Torsional eye movements ! VNG VEMP Dynamic Visual Acuity Evaluates the functional impact of ↓VOR function Static/Dynamic VA Normal VOR : SVA is = DVA Abnormal VOR : DVA is significantly worse than SVA SVV Deviation from the objective vertical axis Static & dynamic conditions Normal SVV is 0° ± 2.5° SVV Bucket test (Munich) app POSTUROGRAPHY Modified Clinical Test of Sensory Interaction on Balance (mCTSIB) Limits of Stability (LOS) Rhytmic Weigth Shift (RWS) Weight Bearing Squat (WBS) Unilateral Stance Sit to Stand Walk Across Tandem Walk Step/Quick Turn Step Up/Over Forward Lunge THANK YOU FOR YOUR ATTENTION