Vertigo

A clinical approach to A clinical approach to the the

diagnosis of vertigodiagnosis of vertigo

John WaterstonJohn Waterston

Alfred Hospital Alfred Hospital

MelbourneMelbourne

Traditional neurological Traditional neurological diagnosisdiagnosis►Localisation of lesion site Localisation of lesion site

““wherewhere””

►Identification of pathology Identification of pathology ““whatwhat””

The vast majority of cases of vertigo are due to peripheral causes or benign central conditions (migraine).

HOWEVER

Is it vertigo?Is it vertigo?

►Definition: an illusion of motionDefinition: an illusion of motion Spinning, dropping, tilting, fallingSpinning, dropping, tilting, falling ““something moving inside my head”something moving inside my head”

►Usually aggravated by head movementsUsually aggravated by head movements►Differential diagnosis largeDifferential diagnosis large

Anxiety and hyperventilationAnxiety and hyperventilation Postural hypotensionPostural hypotension

Syndrome approachSyndrome approach

►Acute, chronic or recurrentAcute, chronic or recurrent

►Spontaneous or (head) Spontaneous or (head) motion-inducedmotion-induced

4 key syndromes4 key syndromes

►Acute vestibulopathyAcute vestibulopathy►Recurrent vestibulopathyRecurrent vestibulopathy►Motion-induced vertigoMotion-induced vertigo►DisequilibriumDisequilibrium

} spontaneous

1. 1. Acute vestibulopathyAcute vestibulopathy

Vestibular neuritis

Stroke (PICA, AICA) Perilymph fistula

Trauma

Vestibular neuritis (neuronitis)Vestibular neuritis (neuronitis)

►A common cause of acute vertigoA common cause of acute vertigo►Many cases thought to be due to Many cases thought to be due to

reactivation of herpes simplex Ireactivation of herpes simplex I►Similar pathogenesis to Bell’s palsySimilar pathogenesis to Bell’s palsy►Acute vertigo, unidirectional nystagmusAcute vertigo, unidirectional nystagmus

Normal VOR

Abnormal VOR

Halmagyi & Curthoys, 1988.

Management: Management: Shupak et al, Otology & Neurotology. 2008. 29:368-374.Shupak et al, Otology & Neurotology. 2008. 29:368-374.Strupp et al, NEJM. 2004. 351:354-361.Strupp et al, NEJM. 2004. 351:354-361.

►Prednisolone aids clinical and laboratory Prednisolone aids clinical and laboratory recoveryrecovery 1 mg/kg for 5 days, followed by reducing dose 1 mg/kg for 5 days, followed by reducing dose

over next 15 days.over next 15 days.

►Valacyclovir ineffectiveValacyclovir ineffective►Other treatmentOther treatment

prochlorperazine, promethazineprochlorperazine, promethazine

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

HINTS (high stroke risk)HINTS (high stroke risk)

►HHead ead ►IImpulse (normal)mpulse (normal)

►NNystagmus (direction changing)ystagmus (direction changing)

►TTest ofest of►SSkew deviation (present)kew deviation (present)

Benign HINTS examination result at thebedside “rules out” stroke better than a negative MRI with DWI in the first 24 to 48 hours after symptom onsetThe sensitivity of early MRI with DWI for lateral medullary or pontine infarction was lower than that of the bedside examination (72% versus 100%)

2. 2. Recurrent vestibulopathyRecurrent vestibulopathy

Migraine

Meniere’s disease Vertebro-basilar insufficiency

Vestibular paroxysmia

Focal epilepsy

Episodic ataxia

3. 3. Motion induced vertigoMotion induced vertigoUncompensated peripheral lesion

Benign positional vertigo Migraine

Cerebellar disease

Cervical vertigo

Usually respond to physical treatment modalities

Benign positional vertigoBenign positional vertigo

►~25% of cases of vertigo.~25% of cases of vertigo.►May be primary or secondary.May be primary or secondary.►Short-lived bouts of vertigo.Short-lived bouts of vertigo.►Positional featuresPositional features

in bed, head extension (in bed, head extension (““top shelf vertigotop shelf vertigo””), ), bending.bending.

►Usually curable!Usually curable!

Mechanism of benign positional vertigo

DiagnosisDiagnosis

►Must see nystagmus with vertigoMust see nystagmus with vertigo►Patients with other vestibular disorders will Patients with other vestibular disorders will

often feel dizzy during the Hallpike often feel dizzy during the Hallpike manoeuvremanoeuvre

►Spontaneous or central nystagmus may be Spontaneous or central nystagmus may be more prominent during positional testingmore prominent during positional testing

Epley manoeuvre (right sided BPV)

Semont manoeuvre for right sided BPV

Brandt-Daroff exercises for management of benignpositional vertigo (posterior canal)

Acta Otolaryngol. 1980;106:484-485

4. 4. DisequilibriumDisequilibrium► CNSCNS

cerebellar diseasecerebellar disease normal pressure hydrocephalusnormal pressure hydrocephalus multi infarct statemulti infarct state

► Proprioceptive lossProprioceptive loss spinal diseasespinal disease peripheral neuropathyperipheral neuropathy

► OtherOther bilateral vestibular hypofunctionbilateral vestibular hypofunction ageingageing hypothyroidismhypothyroidism multi-sensory dizziness/disequilibriummulti-sensory dizziness/disequilibrium (visual, vestibular, (visual, vestibular,

cervical spine, neuropathy, orthopaedic)cervical spine, neuropathy, orthopaedic)

““Red FlagsRed Flags””►Other neurological signsOther neurological signs►Ataxia out of proportion to vertigoAtaxia out of proportion to vertigo►Nystagmus out of proportion to vertigoNystagmus out of proportion to vertigo►Central nystagmusCentral nystagmus

vertical, gaze evoked, dissociated, acquired vertical, gaze evoked, dissociated, acquired pendularpendular

►Central eye movement abnormalitiesCentral eye movement abnormalities broken pursuit , gaze palsy, dysmetric or slow broken pursuit , gaze palsy, dysmetric or slow

saccades, skew deviationsaccades, skew deviation

SummarySummary►Learn to differentiate between spontaneous Learn to differentiate between spontaneous

and (head) motion induced vertigoand (head) motion induced vertigo►Think of migraine, particularly in the younger Think of migraine, particularly in the younger

patient presenting with unexplained recurrent patient presenting with unexplained recurrent vertigo.vertigo.

►Vertebro-basilar ischaemia is a rare diagnosisVertebro-basilar ischaemia is a rare diagnosis►Examine the eye movements carefullyExamine the eye movements carefully►Do a Hallpike test (except when there is Do a Hallpike test (except when there is

obvious spontaneous nystagmus).obvious spontaneous nystagmus).