VERTIGO

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Dr. Riki Sukiandra, SpS Bagian / SMF Saraf FK UNRI

Vertigo or dizziness is a symptom, not a disease

Vertigo
is the feeling that you or your environment is moving when no movement occurs

The sensation of movement is called

subjective vertigo

The perception of movement in surrounding objects

is called

objective vertigo

vestibular system
structures of the inner ear, the vestibular nerve, brainstem, cerebellum

Vestibular system
integrating sensory stimuli and movement keeping objects in visual focus as the body moves.

Vertigo occurs as a result of a disorder in the vestibular system

When the head moves, signals are transmitted to the labyrinth, which is an apparatus in the inner ear that is made up of three semicircular canals surrounded by fluid. The labyrinth then transmits movement information to the vestibular nerve and the vestibular nerve carries the information to the brainstem and cerebellum (areas of the brain that control balance, posture, and motor coordination). There are a number of different causes for dizzy spells.

Causes
peripheral (structures of

the inner ear) central (n.vestibular , brainstem, and cerebellum)

unknown

Peripheral disorders
BPPV (Benign paroxysmal positional vertigo) Cogan's syndrome Mnire disease Ototoxicity Vestibular neuritis

Benign paroxysmal positional vertigo (BPPV)

most common peripheral disorder; may be accompanied by hearing loss, reduced cognitive function, facial muscle weakness

Cogan's syndrome
inflammation of connective tissue in the cornea; results in vertigo, tinnitus, loss of hearing

Mnire disease
fluctuating pressure of endolymph, results in severe vertigo, tinnitus, progressive hearing loss

 Ototoxicity ;
ear poisoning)

Vestibular neuritis ;
inflammation of vestibular nerve cells; may be caused by viral infection)

Central disorders
Cardiovascular disorders CNS disorders Head trauma Migraine Multiple sclerosis Orthostatic hypotension Systemic diseases Tumors

CV disorders :
bradycardia tachycardia

CNS disorders :
stroke infarction brain hemorrhage decreased blood flow to the brain

Cerebellar hemorrhage
vertigo, headache difficulty walking, inability to look toward the side of the bleed.

Head trauma and neck injury

may also result in vertigo

Migraine
3050% of patients experience vertigo vertigo is usually followed by a headache

Multiple sclerosis
demyelination affects the brainstem or cerebellum

Orthostatic hypotension
sharp decrease in blood pressure upon rising from a lying or sitting position to a standing position; caused by diabetes, dehydration, and anemia

Systemic diseases ;
kidney disease, thyroid disorders

Tumors vestibular system ;

acoustic neuroma

Signs and Symptoms Vertigo, or dizziness, refers to the sensation of spinning (subjective vertigo) or the perception that surrounding objects are moving or spinning (objective vertigo)

Sudden onset of vertigo usually indicates a peripheral vestibular disorder

Symptoms of BPPV
last a few seconds to a few minutes Intermittent lightheadedness, imbalance, nausea, a result of a change in position

Symptoms of Meniere disease and vestibular neuritis

vertigo, hearing loss, tinnitus ear pressure

Peripheral vestibular disorders

Blurred vision Fatigue and reduced stamina Headache Heart palpitations Imbalance Inability to concentrate Increased risk for motion sickness Muscle ache (especially of the neck and back) Nausea and vomiting Reduced cognitive function Sensitivity to bright lights and noise Sweating

Central vestibular disorder

Diplopia Headache Impaired consciousness Dysarthria Lack of coordination Nausea and vomiting Weakness

BPPV
most common form characterized by the sensation of motion initiated by sudden head movements

Dix-Hallpike maneuver (used to diagnose benign paroxysmal positional vertigo). This test consists of a series of two maneuvers: With the patient sitting on the examination table, facing forward, eyes open, the physician turns the patient's head 45 degrees to the right (A). The physician supports the patient's head as the patient lies back quickly from a sitting to supine position, ending with the head hanging 20 degrees off the end of the examination table. The patient remains in this position for 30 seconds (B). Then the patient returns to the upright position and is observed for 30 seconds. Next, the maneuver is repeated with the patient's head turned to the left. A positive test is indicated if any of these maneuvers provide vertigo with or without nystagmus.

Labyrinthitis
inflammation within the inner ear, sudden onset of vertigo, associated with hearing loss.

Meniere disease
triad of symptoms:
episodes of vertigo, tinnitus, hearing loss

abrupt onset of severe vertigo, fluctuating hearing loss, periods symptom-free.

Acoustic neuroma
tumor causing vertigo. vertigo one-sided tinnitus one-sided hearing loss.

Clues to Distinguish Between Peripheral and Central Vertigo

Clues
Findings on Dix-Hallpike maneuver Latency of symptoms and nystagmus Severity of vertigo Duration of nystagmus Fatigability* Habituation Other findings Postural instability Hearing loss or tinnitus Other neurologic symptoms 2 to 40 seconds Severe Usually less than 1 minute Yes Yes None Mild Usually more than 1 minute No No

Peripheral vertigo

Central vertigo

Able to walk; unidirectional instability

Can be present Absent

Falls while walking; severe instability

Usually absent Usually present

Diagnosis
includes clinical history, physical and neurological examination, blood tests, and imaging tests (e.g., CT scan, MRI scan). It is important to diagnose the cause of vertigo, or dizziness as quickly as possible to rule out serious conditions such as cardiovascular disease, stroke, hemorrhage, or tumor.

Differential Diagnosis of Vertigo

Disorder
Benign paroxysmal positional vertigo Perilymphatic fistula (head trauma, barotrauma) Vascular ischemia: transient ischemic attack Mnire's disease Syphilis Vertiginous migraine Labyrinthine concussion Labyrinthitis Vascular ischemia: stroke Vestibular neuronitis

Duration of episodes
Seconds Seconds Seconds to hours Hours Hours Hours Days Days Days Days

Auditory symptoms
No Yes Usually not Yes Yes No Yes Yes Usually not No

Prevalence
Common Uncommon Uncommon Common Uncommon Common Uncommon Common Uncommon Common

Peripheral or central vertigo

Peripheral Peripheral Central or peripheral* Peripheral Peripheral Central Peripheral Peripheral Central or peripheral* Peripheral

Anxiety disorder
Acoustic neuroma Cerebellar degeneration Cerebellar tumor Multiple sclerosis Vestibular ototoxicity

Variable
Months Months Months Months Months

Usually not
Yes No No No Yes

Common
Uncommon Uncommon Uncommon Uncommon Uncommon

Unspecified
Peripheral Central Central Central Peripheral

Important considerations
1. 2. 3. 4. What triggers the vertigo? What other symptoms occur? How long does the dizziness last? What improves or worsens symptoms?

 have these symptoms:

nausea or vomiting , sweating, abnormal eye movements

the duration ;
from minutes to hours, constant or episodic

the onset ;
due to movement or change in position

 recent head trauma or whiplash injury

medications you may be taking hearing loss and a ringing sensation

visual disturbances, weakness,

difficulty speaking, decreased level of consciousness, and difficulty walking

Signs and symptoms may require evaluation in an emergency department

Double vision Headache Weakness Difficulty speaking Abnormal eye movements Altered level of consciousness, not acting appropriately, or difficulty arousing Difficulty walking or controlling your arms and legs

Medications Commonly Used In Patients with Acute Vertigo and Associated Nausea and Emesis
Medication
Meclizine* (Antivert) Dimenhydrinate* (Dramamine)

Dosage
12.5 to 50 mg orally every 4 to 8 hours 25 to 100 mg orally, IM, or IV every 4 to 8 hours

Sedation
++ +

Antiemesis
+ ++

Pregnancy category
B B

Diazepam (Valium)
Lorazepam (Ativan)

2 to 10 mg orally or IV every 4 to 8 hours

0.5 to 2 mg orally, IM, or IV every 4 to 8 hours

++
++

+
+

D
D

Metoclopramide (Reglan)

5 to 10 mg orally every 6 hours 5 to 10 mg by slow IV every 6 hours

+++

Prochlorperazine (Compazine)

5 to 10 mg orally or IM every 6 to 8 hours 25 mg rectally every 12 hours 5 to 10 mg by slow IV over 2 minutes

+++

Promethazine (Phenergan)

12.5 to 25 mg orally, IM, or rectally every 4 to 12 hours

+++

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