Acute Vertigo, Ambulatory Case Conf

8/8/2019 Acute Vertigo, Ambulatory Case Conf

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VERTIGO


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IDENTIFICATION DATA

24 . .


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CHIEF COMPLAIN

15 .


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PRESENT ILLNESS

15 . 10 .

3-4

,


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OTHER INFORMATIONS


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PHYSICAL EXAMINATION

Abdomen : Soft, Normal contour, Active bowel

sound, no rebound tenderness, no

Hepatosplenomegaly

Ext : no edema , no skin lesion

LN : no lymphadenopathy


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NEUROLOGIC EXAMINATION

Alert, Orientation*III

CN II : No RAPD, No visual field defect

CN III, IV, VI : Pupils3mm RTLBE. Full EOM, Horizontalnystagmusto right (cansuppress by fixation)

CNV : No jaw deviation, Corneal Reflex +ve, CNVII : No facial palsy

CNVIII : Weber > No lateralization, Rinne > AC> BC Bothsides, Head Thrust-ve

CN

IX & X : uvulain

mi

dlin

e. Gag reflex

+ve CN XI : Normal Trapezius and Sternocleidomastoid motor

power bothsides

CN XII : No Tongue deviation


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COCHLEAR NERVE EVALUATION


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NEUROLOGICAL EXAMINATION

No cerebellar sign

No motor deficit

No sensoryimpairment DTR 2 + all

MMSE > 29/30

No auditory agnosia


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PROBLEM LISTS

Acute onset of vertigo


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VERTIGO

Latin origin: vertere, to spin

The illusionthatthe environmentisspinning

Distinct from dizziness light-headed faintness

off-balanced feeling

feeling of floating


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ANATOMY AND PHYSIOLOGY


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TYPES OF VERTIGO

Central vestibular causes (Brainstem or

cerebellum)

Peripheral vestibular causes ( Labyrinth orvestibular nerve)


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CAUSES OF VERTIGO

CENTRAL

Cerebrovascular Disease

Migraine

Multiple Sclerosis Neurodegenerative Disorders

Epilepsy

Inherited Disorders

Familial BilateralVestibulopathy

Familial Hearing loss and

Vertigo

Familial Ataxia Syndromes

PERIPHERAL

Vestibular Neuritis

BPPV

Meniers Disease Vestibular Paroxysmia

Perilymphatic Fistula

Other Peripheral Disorders

Drugs Toxins

Acoustic Neuroma


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CAUSES..

Drugs

Alcohol

Aminoglycosides

Anticonvulsants Antidepressants

Antihypertensives

Barbiturates

Cocaine


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HISTORY

Timings

Duration

Provoking, aggravating factors

Associated symptoms Risk factors for Cardiovascular disease


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General Medical Examination

General Neurological Examination

Ocular motor function Facial strength and symmetry

Observing palatal elevation, tongue protrusion, and

trapezius and sternocleidomastoid strength

Coordination (Ataxia, the finger-nose-finger test, the

heel-knee-shintest, and rapid alternating

movements)


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The Neurotological Examination Ocular Motor Function Testing

Gaze Testing

Smooth Pursuit

Saccades Optokinetic Nystagmus and FixationSuppression ofthe

Vestibulo-ocular Reflex

Vestibular Nerve Examination

Positional Testing

Fistula Testing

Gait Assessment

AuditoryExamination


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OCULAR MOTOR FUNCTION TESTING

Nystagmusis characterized by a slow and fast

phase component and is classified as

spontaneousspontaneous, gazegaze--evokedevoked, or positionalpositional. The

direction ofnystagmusis described

conventionally bythe direction ofthe fastthe direction ofthe fast

phasephase.

Spontaneousnystagmus canhave either aperipheral or a central pattern.


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OCULAR MOTOR FUNCTION TESTING

Central lesions canmimic a peripheral

pattern ofnystagmus but peripheral lesions

cannot cause central patterns ofnystagmus.

Saccadic intrusions

Square wave jerks- normal intersaccadic delay

Saccadic oscillations- do nothave the

intersaccadic intervalOcular Flutter - Horizontal

Opsoclonus Vertical or Torsional


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NYSTAGMUS

Nystagmus of Central Origin

May be purely vertical

May be purelyhorizontal

May be horizonto-rotary

May change direction with gaze

Not diminished by fixation


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NYSTAGMUS

Nystagmus of Peripheral Origin

Horizontal and torsional

Diminished by fixation

May fatigue (if elicited byhead movement)

Doesnot change direction with gaze change

Diminishes with fixation


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Cluesto Distinguish Between Peripheral and Central Vertigo

Clues Peripheral vertigo Central vertigo

Findings on Dix-Hallpike

maneuver

Latency ofsymptoms and

nystagmus2to 40

seconds

None

Severity of vertigo Severe Mild

Duration ofnystagmus Usually< 1 minute Usually>1 minute

Fatigability Y es No

Other findings

Postural instability Able to walk;

unidirectional instability

Falls while walking;severe

instability

Hearing loss or tinnitus Can be present Usually absent

Other neurologic

Symptoms

Absent Usually present


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SMOOTH PURSUIT AND SACCADES

Abnormalities ofsmooth pursuit occur asthe result of

disordersthroughoutthe central nervoussystem and

with use oftranquilizingmedicines or alcohol and with

fatigue. Saccades are generated bythe burstneurons ofthe

pons (horizontal movements) and the midbrain

(vertical movements).

Lesions or degeneration ofthese regions leadsto

slowing ofsaccades

Ocular dysmetria (Overshootingsaccades) - indicates

a lesion ofthe cerebellum.


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VESTIBULAR NERVE EXAMINATION


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POSITION TESTING

Dix-Hallpike test

Positional testing usingthe head-hangingtechnique

patients with benign positional vertigo will show a

burst ofnystagmus after a delay of 5 to 10

seconds, the nystagmus lasts about30 seconds

The testisnever subtly positive


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DIX-HALLPIKE TEST


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PATHOLOGY AND PHYSICAL

EXAMINATION


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CHARACTERISTICS OF PERIPHERAL

VERTIGO


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CHARACTERISTICS OF CENTRAL

VERTIGO


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RED FLAGS OF ACUTE VERTIGO

Any central neurological symptoms or signs

New type ofheadache (especially occipital)

Acute deafness Vertical nystagmus


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COMMON PRESENTATIONS OF

VERTIGO

Acute Severe Vertigo

Focal neurological symptoms, particularlythosethat can be related to the posterior circulation,

suggests anischemic strokeischemic stroke If a peripheral vestibular pattern ofnystagmusis

identified, a positive result onhead thrusttestinglocalizesthe lesionto the vestibular nerve

Young patient > Vestibular neuritisVestibular neuritisOlder patient > Acute ischemia ofthe vestibular nerve orAcute ischemia ofthe vestibular nerve or

vestibular labyrinth cannot be excludedvestibular labyrinth cannot be excluded


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VERTIGO

Acute Severe Vertigo

Ifhearing loss accompaniesthe episode, Labyrinthitisisthe most likely diagnosis

Whenhearing loss and facial weakness accompanyacute-onset vertigo, the examiner should closelyinspectthe outer ear for vesicles characteristic ofHerpeszoster (RamsayHuntsyndrome)Herpeszoster (RamsayHuntsyndrome)

MigraineMigraine canmimic vestibular neuritis, althoughthe

diagnosis ofmigraine - associated vertigo hinges onrecurrent episodes and lack of progressive auditorysymptoms


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VERTIGO

Recurrent Attacks ofVertigo

Meniere's diseaseMeniere's disease isthe likely cause in patientswith recurrent vertigo lasting longer than20

minutes and associated with unilateral auditorysymptoms

Transientischemic attacks (TIAs)Transientischemic attacks (TIAs)should besuspected in patients who experience brief

episodes (minutesin duration) of vertigo,particularly when vascular risk factors are presentand other neurological symptoms are reported


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VERTIGO

Recurrent Attacks ofVertigo

The migraine equivalentmigraine equivalent, benign recurrent vertigo,

is characterized by a history ofsimilar symptoms,

normal findings on physical examination, family orpersonal history ofmigraine headaches, and typical

triggers.


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VERTIGO

Recurrent Positional Vertigo

Inthe patient complaining of recurrent episodes of

vertigo triggered by certainhead movements, the

likely diagnosisis BPPVBPPV

The historystronglysuggeststhe diagnosis of BPPV

whenthe positional vertigo is brief (duration less

than 1 minute), hastypical triggers, and is

unaccompanied by other neurological symptoms


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VERTIGO


Central positional nystagmus occurs asthe result ofdisorders affectingthe posteriorposterior fossafossa includingincluding

tumors,tumors, cerebellarcerebellar degeneration,degeneration, ChiariChiarimalformation, and MSmalformation, and MS

Following loss of one vertebral arteryloss of one vertebral artery, vertigo orsignificant dizziness after head turnsto the

direction opposite the intact arterymay develop,because the bonystructures ofthe spinal columncan pinch offthe remaining vertebral artery


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VERTIGO


Patients withmigrainemigraine asthe cause typically report

a longer duration ofsymptoms once the positional

vertigo istriggered, and the nystagmusmay be of acentral or peripheral type


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DIAGNOSIS

History

Physical Exam

Neurologic Exam

No Laboratory Investigation Brain Imaging


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GENERAL TREATMENT PRINCIPLES

Medication for Acute Vertigo that lasts for few hoursto

several days

Medicationshave various combinations of

acetylecholine, dopamineand histamine receptorantagonism.

Benzodiazepines enhance GABA action ( GABA is

inhibitoryneurotransmitter in vestibular system)


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STRENGTH OF RECOMMENDATION

The canalith repositioning procedure (Epleymaneuver)is recommended in patients with benignparoxysmal positional vertigo. A

The modified Epley maneuver also is effective in

patients with benign paroxysmal positional vertigo. B Vestibular suppressantmedicationis recommended

for symptom reliefin patients with acute vestibularneuronitis. C

Vestibular exercises are recommended for more rapidand complete vestibular compensationin patientswith acute vestibular neuronitis. B

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus,disease-oriented evidence, usual practice, opinion, or case series.


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STRENGTH OF RECOMMENDATION

Treatment with a low-salt diet and diureticsisrecommended for patients with Mnire's disease andvertigo. B

Effective treatments for vertiginousmigraine include

migraine prophylaxis (e.g., tricyclic antidepressants,beta blockers, calcium channel blockers), migraine-abortive medications (e.g., sumatriptan), andvestibular rehabilitation exercises. B

Selective serotonin reuptake inhibitors can relievevertigo in patients with anxiety disorders. Because ofside effects, slow titrationis recommended. B

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus,disease-oriented evidence, usual practice, opinion, or case series. See page 1046 for more information.


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MEDICATIONS

Meclizine* (Antivert) 12.5 to 50 mg orally every4to 8 hour

Dimenhydrinate* (Dramamine)25 to 100 mg

orally, IM, or IV every4to 8 hours Diazepam (Valium)2to 10 mg orally or IV every4to 8 hours

Lorazepam (Ativan) 0.5 to 2mg orally, IM, or IVevery4to 8 hours


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MEDICATIONS

Metoclopramide (Reglan) 5 to 10 mg orallyevery6hours; 5 to 10 mg byslow IV every6hours

Prochlorperazine (Compazine) 5 to 10 mg orallyor IM every6to 8 hours25 mg; rectally every12hours; 5 to 10 mg byslow IV over 2minutes

Promethazine (Phenergan) 12.5 to 25 mgorally, IM, or rectally every4to 12hours


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VESTIBULAR REHABILITATION

EXERCISES

These exercisestrainthe brainto usealternative visual and proprioceptive cluestomaintain balance and gait

Improve postural control duringthe firstmonthafter acute unilateral vestibular lesionsresulting from vestibular neuronitis


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TREATMENT OF BPPV

Medications

Head Rotation Maneuvers : Epley Maneuver

Contraindication: Severe carotid stenosis,

unstable heart disease, severe neck disease

Success rate: 80 % after one treatment, 100%with repeated treatments.

Recurrence rates: 15% /year, 20% at20months, and 37% at60 months.


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TREATMENT OF BPPV

Epleymaneuver

The patientshead issystematically rotated to move

the loose particles out ofthe posterior semicircular

canal backinto the utricle


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TREATMENT OF BPPV


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TREATMENT OF VESTIBULA

NEURONITIS

Symptom relief using vestibular suppressantmedications, followed by vestibular exercises.

Vestibular compensations occursmore rapidly

and more completelyifthe patient beginstwice-daily vestibular rehabilitation exercisessoon after symptom control withmedications.


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TREATMENT OF MENIERS DISEASE

Low salt diet ( < 1-2 gm/day)

Diuretics

Surgeryin rare cases-

ablation of vestibularhair cells)


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TREATMENT OF VASCULAR ISCHEMIA

TIA /Stroke: BP control, Cholesterol Lowering ,smoking cessation, inhibition of plateletfunction, anticoagulation

Vestibular suppressantmedications plusminimal head maneuver on first day, theninitiate rehabilitation

Vestibular stents for symptomatic criticalvertebral arterystenosis


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THEEND

Acute Vertigo, Ambulatory Case Conf

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