Vertigo

Balance system
Sensory input Vestibular apparatus Vision Propriocepti on Integrating mechanism Vestibular nuclei Cerebellum Extrapyrami dal system Limbic system Cerebral cortex Effector organ Locomotor system Eye movement

Difficult in diagnosis
Complexity of balance system Adaptation of system
Uni-bilateral Acute-chronic

Varies of symptoms Various etiology

Systemic Degeneration Aging

Compensatory mechanism in human

Vestibular compensation
Adaptation and learn new behavior Rapid symptom recovery following peripheral pathology

Variety of process
Adaptation/habituation: recalibration of the gain of the vestibular reflex Substitution of sensory input and motor response, together with alteration of stretegies used for balance

Syndrome of vertigo: base on connection

Major symptoms Psychiatric symptoms: fear Vertigenous sensation Anxiety Imbalance Hyperventilation Nystagmus and syndrome oscillopsia Phobia Autonomic dysfunction
N/V Palpitation Fluctuation in BP

Interaction of autonomic, psychological, and vestibular symptoms

Dizzy symptoms

True vertigo
S/S Latency Duration Fatigability Nystagmus direction Peripheral 0-40 sec <1 min Yes Direction fixed, torsional, up, upper pole of eye toward ground Severe vertigo, nystagmus, nausea

Non-vertigenous dizziness Syncope Disequilibrium Ill-define symptoms

Central No latency May persist No Direction changing variable

! Intensity of S/S !
reproducibility

Inconsistent

Mild vertigo, less intense nystagmus, rare nausea More consistent

Most helper differential causes Time course - onset

Identify causes

Otological disorder Neurological disorder Systemic disorder

Causes of vertigo
Peripheral vertigo
Infection/inflammation
Peripheral vestibulopathy
Vestibular neuritis, acute neurolabyrinthitis Localized: CN7+8 affected: Ramsay Hunt syndrome Systemic: mump, measle, IM, URI

Trauma: post-traumatic vertigo Local tumor Vascular: rare Metabolic/ toxic

Aminoglycoside(rare)

Central vertigo Common is Tumor: CP angle tumor Demyelinating: MS Vascular: ischemia(VBI) Posterior fossa lesion Migraine Vertigenous epilepsy

Other: BPPV, Menieres disease

Systemic causes of vertigo and dizziness

Drugs
AED, hypnotic, alcohol, analgesic

Hypotension, presyncope Infectious disease

Syphilis, viral, systemic infection

Endocrine disease
Diabetes, hypothyroidism

Vasculitis Others: hematological, granulomatous disease, systemic toxin

Some point
Acute vestibular vertigo Mimicker peripheral VS central Some central cause: only vertigo S/S Acute can caused by vascular VS nonvascular Episodic caused by various etiology Pattern recognition: Use anatomical and time course-onset together

Time course-onset
Lasting for day or longer Peripheral: vestibular neuritis Central: brainstem stroke, MS Lasting for hours or minute Peripheral: Menieres disease Central: TIA, migraine, seizure Lasting for second Peripheral: BPPV

Vertigo lasting for day or longer

Vestibular neuritis Acute Few hours, peaks in day, improve within day to weeks Viral or post viral? Brain stem stroke Sudden Evidence of vertebrobasilar ischemia Some can mimick peripheral cause: inferior cerebellar and flocculonodular lobe

Distinguishing vestibular neuritis from stroke(in absence of others brain stem signs)
Nystagmus Direction Fixation Postural instability Severity Direction of instability

Peripheral vertigo management

Five main arms of management intervention: General medical evaluation, with correction/ ameliorationnof associated morbid conditions Pharmacological intervention Vestibular rehabilitation with physiotherapy and specific physical manoeuvres for the management of benign positional paroxysmal vertigo Psychological intervention Surgery

Vascular cause of vertigo

Location of lesion Paramedian infratentorial lesion Thalamus Vertibular cortex Vascular territory Vertebrobasilar system Middle cerebral artery