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Vertigo
- 1. A clinical approach to the diagnosis of vertigo John Waterston Alfred Hospital Melbourne
- 2. Traditional neurological diagnosis âșLocalisation of lesion site âwhereâ âșIdentification of pathology âwhatâ
- 3. HOWEVER The vast majority of cases of vertigo are due to peripheral causes or benign central conditions (migraine).
- 4. Is it vertigo? âș Definition: an illusion of motion ï§ Spinning, dropping, tilting, falling ï§ âsomething moving inside my headâ âș Usually aggravated by head movements âș Differential diagnosis large ï§ Anxiety and hyperventilation ï§ Postural hypotension
- 5. Syndrome approach âșAcute, chronic or recurrent âșSpontaneous or (head) motion- induced
- 6. 4 key syndromes âșAcute vestibulopathy âșRecurrent vestibulopathy } spontaneous âșMotion-induced vertigo âșDisequilibrium
- 7. 1. Acute vestibulopathy Vestibular neuritis Stroke (PICA, AICA) Perilymph fistula Trauma
- 8. Vestibular neuritis (neuronitis) âșA common cause of acute vertigo âș Many cases thought to be due to reactivation of herpes simplex I âș Similar pathogenesis to Bellâs palsy âș Acute vertigo, unidirectional nystagmus
- 9. Normal VOR Abnormal VOR Halmagyi & Curthoys, 1988.
- 10. Management: Shupak et al, Otology & Neurotology. 2008. 29:368-374. Strupp et al, NEJM. 2004. 351:354-361. âș Prednisolone aids clinical and laboratory recovery ï§ 1 mg/kg for 5 days, followed by reducing dose over next 15 days. âș Valacyclovirineffective âș Other treatment ï§ prochlorperazine, promethazine
- 11. HINTS to Diagnose Stroke in the Acute Vestibular Syndrome Three-Step Bedside Oculomotor Examination More Sensitive Than Early MRI Diffusion- Weighted Imaging Jorge C. Kattah, MD; Arun V. Talkad, MD; David Z. Wang, DO; Yu-Hsiang Hsieh, PhD, MS; David E. Newman-Toker, MD, PhD Stroke 2009;40;3504-3510
- 12. HINTS (high stroke risk) âșHead âșImpulse (normal) âșNystagmus (direction changing) âșTest of âșSkew deviation (present)
- 14. Benign HINTS examination result at the bedside ârules outâ stroke better than a negative MRI with DWI in the first 24 to 48 hours after symptom onset The sensitivity of early MRI with DWI for lateral medullary or pontine infarction was lower than that of the bedside examination (72% versus 100%)
- 15. 2. Recurrent vestibulopathy Migraine Meniereâs disease Vertebro-basilar insufficiency Vestibular paroxysmia Focal epilepsy Episodic ataxia
- 16. 3. Motion induced vertigo Uncompensated peripheral lesion Benign positional vertigo Migraine Cerebellar disease Cervical vertigo Usually respond to physical treatment modalities
- 17. Benign positional vertigo âș ~25% of cases of vertigo. âș May be primary or secondary. âș Short-lived bouts of vertigo. âș Positional features ï§ in bed, head extension (âtop shelf vertigoâ), bending. âș Usually curable!
- 18. Mechanism of benign positional vertigo
- 19. Diagnosis âș Must see nystagmus with vertigo âș Patients with other vestibular disorders will often feel dizzy during the Hallpike manoeuvre âș Spontaneous or central nystagmus may be more prominent during positional testing
- 20. Epley manoeuvre (right sided BPV)
- 21. Semont manoeuvre for right sided BPV
- 22. Brandt-Daroff exercises for management of benign positional vertigo (posterior canal) Acta Otolaryngol. 1980;106:484-485
- 23. 4. Disequilibrium âș CNS ï§ cerebellar disease ï§ normal pressure hydrocephalus ï§ multi infarct state âș Proprioceptive loss ï§ spinal disease ï§ peripheral neuropathy âș Other ï§ bilateral vestibular hypofunction ï§ ageing ï§ hypothyroidism ï§ multi-sensory dizziness/disequilibrium (visual, vestibular, cervical spine, neuropathy, orthopaedic)
- 24. âRed Flagsâ âș Other neurological signs âș Ataxia out of proportion to vertigo âș Nystagmus out of proportion to vertigo âș Central nystagmus ï§ vertical, gaze evoked, dissociated, acquired pendular âș Central eye movement abnormalities ï§ broken pursuit , gaze palsy, dysmetric or slow saccades, skew deviation
- 25. Summary âș Learn to differentiate between spontaneous and (head) motion induced vertigo âș Think of migraine, particularly in the younger patient presenting with unexplained recurrent vertigo. âș Vertebro-basilar ischaemia is a rare diagnosis âș Examine the eye movements carefully âș Do a Hallpike test (except when there is obvious spontaneous nystagmus).