Vertigo

DDX: 1

Peripheral 1

Central 1

BPPV (Benign paroxysmal positional vertigo) 1

Vestibular Neuritis 2

Meniere’s Disease 2

Definitions and assessment

Note:

- Vertigo is a symptom NOT a diagnosis.

- Trying to attribute a specific description to a patients symptoms is often impossible.

Vertigo	The sensation of self-motion when no self-motion is occurring, or the sensation of distorted self-motion during an otherwise normal head movement
Dizziness	The sensation of disturbed or impaired spatial orientation without a false or distorted sense of motion
Unsteadiness	The feeling of being unstable while steated, standing, or walking with a particular directional preference
Oscillopsia	The false sensation that the visual surround is oscillating
Presyncope	The sensation of impending loss of consciousness
Syncope	Transient loss of consciousness due to transient global cerebral hypoperfusion, characterized by rapid onset, short duration and spontaneous, complete recovery.

Symptom patterns to determine diagnosis pathway:

Traditional division:

1. Vertigo – vestibular cause
2. Presyncope - Cardiac cause
3. Disequilibrium – neurological cause
4. Non-specific – Pschycological or metabolic cause

Newer suggested approach – based on timecourse and triggers, rather than type of dizziness:

1. Acute, spontaneous, prolonged - vestibular neuronitis, stroke
2. Episodic, positional – BPPV
3. Episodic, spontaneous – migraine, Meniere’s
4. Chronic – cerebellar degeneration, bilateral vestibular failure, spinal cord compression.

Diagnosis according to timeframe

	Common causes	Dangerous Mimics
Transient - Seconds to hours	BPPV Orthostatic hypotension Reflex hypotension Panic attack Meniere syndrome Vestibular migraine	TIA Cardiac arrhythmia Other CVS disease Neurohumoural neoplasm (e.g. insulinoma, pheochromocytoma)
Non-episodic – Days to weeks	Vestibular neuritis Viral labyrinthitis Medication toxicity	Brainstem/cerebellar/labyrinthine stroke Bacterial labyrinthitis/mastoiditis Herpes zoster oticus Brainstem encephalitis Miller fisher syndrome Medication toxicity (e.g. lthium, alcohol, carbon monoxide)

Triggers

Standing up	Orthostatic hypotension BPPV
Rolling over (while lying)	BPPV
Head movement	Non-specific – will worsen most forms of dizziness
Occur only during head movement	Unilateral or bilateral vestibular loss Vestibular migraine
Eye Movement (head still)	Vestibular migraine

DDX:

Peripheral

• BPPV
• Vestibular neuritis/ Acute Labyrinthitis
• Meniere’s disease
• Herpes Zoster oticus
• Labyrinthine concussion
• Otosclerosis
• Perilymphatic fistula
• Semicircular canal dehiscence syndrome
• Cogans syndrome
• Recurrent vistibulopathy
• Acoustic neuroma
• Drugs - Aminoglycoside toxicity
• Alcohol
• High dose salicylates
• Quinine and Quinidine
• Cis-Platinum
• Otitis media

Central

• Migrainous vertigo
• Brainstem ischaemia
• TIA
• Wallenberg’s syndrome
• Other CVA’s
• Infarction of vestibular structures
• Cerebellar infarction/haemorrhage
• Chiari malformation
• MS
• Episodic ataxia type 2

BPPV (Benign paroxysmal positional vertigo)

• Will occur in 2.4% of adults over lifespan
• Accounts for 1/3 vertiginous patients
• Attributed to calcium debris in the posterior semicircular canal (canalithiasis)
• No age, race sex predilection
• Idiopathic in 35%, remainder follow head injury or other vestibular pathology.
• Brief spinning sensation when turning in bed or tilting head backwards
• Usually lasts seconds rather than minutes
• Nausea, rarely vomiting
• Hall-pike manoeuvre positive in 50 -80%
• Head turned to side while sitting
• Rapidly made supine
• Observed for 30s for nystagmus, usually upbeat and torsional
• Repeat other side
• Watch patient when they sit up, nystagmus may occur to opposite side
• With repetitive testing should fatigue
• Lasts day to weeks and then resolves (mean ~39days in one study)
• Epley manoeuvre
• Brandt Daroff excercises
• Semont manoeuvre
• For left canalithiasis: Turn head to right while sitting, drop to left, hold 30seconds, then lie to right while holding head in same position. Repeat three times a day.
• Eye movements of associated nystagmus are in the plane of the affected canal
• Posterior canal
• 80-90%
• Short lived <30sec
• 1/3 complain of gait instability
• Triggers:
1. Turning over
2. Lying from sitting
3. Sitting from lying
4. Extending the neck to look up
5. Bending over
• Hall-pike – causes upbeat and couterclockwise (to patient) rotation
• 70% idiopathic, 20% traumatic, 10% secondary to inner ear disease (meniere’s or post vestibular neuritis)
• Horizontal canal
• 8-17%
• Purely horizontal
• Shorter latency
• Lasts longer
• Less fatigue able
• Head roll test
1. Flex head 20deg
2. 90deg rotation and observe for nystagmus
3. If patient cant move neck much then can log roll the body
4. You will get left beating on left role and right on right roll (geotrophic canalolithiasis)
1. Opposite with ageotrophic (cupulolithiasis)
5. Bow and lean test
6. The affected side is the side with the strongest response (geotrophic – opposite with apogeotrophic)
• Lempert (BBQ) manoeuvre
• Gufoni
• Prolonged lie with good ear down
• Anterior
• 1-3%
• Downbeat torsional on dix-hallpike
• Can look similar to central cause and imaging should be considered
• Multiple canal BPPV
• Particularly in setting of head trauma
• Individually treat each of the canals – starting with the most affected first
• Subjective BPPV
• Central positional nystagmus
• Head hand nystagmus (?rose test)

http://risc.cnrs.fr

Vestibular Neuritis

• Viral or post-viral inflammatory disorder affecting the vestibular nerve
• Clinical – rapid onset of:
• Severe vertigo
• Nausea and vomiting
• Gait instability
• Signs
• Spontaneous nystagmus that is horizontal or torsional
1. Fast phase beats away from the affected side
2. Supressed with visual fixation and does not change with direction of gaze
• Positive head thrust sign – unable to maintain visual fixation when head thrusted to side
• Gait instability – tendency to toward affected side
• Auditory function - if affected the condition referred to as labyrinthitis
• Imaging may be necessary to distinguish from brainstem infarction
• Severe symptoms usually last 1-2 days, onging symptoms for ~1week,
• May be residual symptoms for many months
• Treatment
• Methylprednisolone and prednisolone shown to improve recovery
• Valacyclovir – no benefit
• Sypmtomatic relief, may be some benefit from:
1. Antihistamines, benzodiazepines, anti-emetics

Meniere’s Disease

• Onset peak 20-40years
• 10-150/100,000
• Bilateral disease ~30%
• Due to endolymphatic hydrops – distortion and distention of the membranous endolymphcontaining portions of the labyrinthine system
• Cause of this is unclear – blockage, viral, immunological
• Clinical triad of:
• Vertigo - episodic
• Tinnitus
• Hearing loss – sensorineural
• Diagnosis
• Clinical combined with tests to rule out other diagnosis (i.e. MRI to exclude schwanoma)
• Treatment
• Modify diet to eliminate potential triggers
• Treat acute attacks as per other vertigo
• Diuretics and betahistine may have some disease modifying activity
• 10% of patients have severe refractory disease and may benefit from surgery
1. Many procedure – some destructive to CNVIII, others aimed as drainage of sac – variable effectiveness

Vestibular Migraine

Symptoms

• Vestibular symptoms triggered by eye movement (with the head still) – may be more specific for this condition.