Howtoapproachvertigopatient?

2010.10.29R1
 Vertigo:asymptomofillusorymovement
arisesfromasymmetryinthevestibularsystem
anillusionofmotion
mostcommon:spinningsensation
 Nystagmus
Vertigo

Nausea,
vomiting

Unsteady gait
Fall
Vestibuloocularreflex
 CauseofVertigo
Peripheralcauses Centralcauses
Benignparoxysmalpositionalvertigo Migrainous vertigo
Vestibularneuritis Brainstemischemia
Herpeszosteroticus (RamsayHunt Cerebellar infarctionandhemorrhage
syndrome) Chiari malformation
Meniere's disease Multiplesclerosis
Labyrinthineconcussion Episodicataxiatype2
Perilymphatic fistula
Semicircularcanaldehiscence
syndrome
Cogan'ssyndrome
Recurrentvestibulopathy
Acousticneuroma
Aminoglycoside toxicity
Otitis media
 History
Physicalexamination
Diagnostictests
 History
Vertigo
Nauseaandvomiting
Posturalinstability
Timecourse
Aggravatingfactors
Associatedsymptoms
Priormedicalhistory
 History
Vertigo:
Spinningqualityofvertiginoussensations:
Notoriouslyunreliable
Timecourse,provokingfactorsandaggravating
factors:moreuseful
Severevertigo:bothacuteperipheralorcentral
Nystagmus >>>symptoms:stronglysuggested
brainstem
 History
N/V
SevereN/V:morecommonwithperipheral
Posturalinstability
Vestibulospinal tract
Central:
moreunsteady(likelyalsoimpairotherpathways?)
Peripheral:usuallyabletowalk
 History
Timecourse
Vertigoisnevercontinuous.
CNSadaptsoverseveralweeks
constant :Constantsusceptibilitytofrequent
episodicdizziness
 History
Timecourse
Recurrent,<1min:BPPV
Single,minutestohours:
Migraine,transientischemiaoflabyrinthor
brainstem
Recurrent,lasthours:Menieres disease
Moreprolonged,severeepisodes,lastfordays:
vestibularneuritis,multiplesclerosis,infarctionto
brainstemorcerebellum
 History
Aggrevating factor
Some:spontaneously
Some:changeheadposition
DDx ofpresyncope andvertigo
Lyingdown,rollingoverinbed
 Aggrevating factor
Allvertigoismadeworsebymovingthehead:cannotdistinguishcauses

Provokedwithspecificheadmovements:
BPPV(rolling overinbed,extendingtheneck)
Bycoughing,sneezing,exertionorloudnoises:
Perilymphatic fistulaorsuperiorcanaldehiscence
Headtrauma:multiplemechanismofvertigo
 Associatedsignsandsymptoms
Vertebrobasilar stroke:alwayswithothersignsof
brainischemia(diplopia,dysarthria)
Deafnessandtinnitus:possibleperipheralorigin
Auralfullness:Menieres disease
PressuresensationwithhightoneSNHL:
perilymphatic fistula
Headache,photophobia,sonophobia:migraine
 Associatedsignsandsymptoms
Priormedicalhistory
Migraine
Strokeriskfactors
HTN,DM,Smoking,Hx ofvasculardiseases:VBI
Pastheadtrauma:
BPPVorperilymphatic fistula
Familyhistoryofvertigo:
rarehereditarychannelopathy
Medicationofototoxicity:
cisplatin,aminoglycosides
 Othersymptoms
Vestibulardysfunctionwithoutvertigo
Chronicinjuryoracutebilateralsymmetricinjury
Tiltillusion:otolithic organorcentralconnection
Dropattacks:suddenlossoftonemediatedby
VSR(Pushedtotheground)
Spatialdisorientation:recoverfromacutevertigo
Oscillopsia:impairedvestibuloocular reflex
blurredvisionwhenwalking
Impairedbalancewithoutvertigo:
aminoglycoside toxicity,acutemidlinecerebellar
 Physicalexam
Nystagmus
Gaitinstability
Otherneurologicsigns
Webertestandrinne test
DixHallpike maneuver
 Physicalexam
Nystagmus
Maintaingazeduringheadmovement byVOR
Slowdriftfromthetarget
Fastcorrectmovement
Alexanderslaw
peripherallesion:
fastphaseawayfromthelesion
Vestibuloocularreflex
 Nystagmus

Peripheral Central
Sometimesreverses
Unidirectional,fastphase
directionwhenpatient
Direction towardthenormalear;never
looksinthedirectionof
reversesdirection
slowphase
Horizontalwithatorsional
Type component,neverpurely Canbeanydirection
torsional orvertical
Effectofvisual
Suppressed Notsuppressed
fixation
 Nystagmus

Peripheral Central
Otherneurologic
Absent Oftenpresent
signs

Unidirectionalinstability, Severeinstability,patient
Posturalinstability
walkingpreserved oftenfallswhenwalking

Deafnessor
Maybepresent Absent
tinnitus
 Gaitinstablility
Peripheral
Falltowardthesideofthelesion
butcanwalk
Central
unabletowalkwithoutfalling
directionofRomberg:vary
Otherneurologicsigns:
negativecannotruleoutcentrallesion
 Officehearingtests
Webertest
SNHL:shifttonormalear
Conductive:shifttoaffectedear
Rinne test
SNHLornormal:AC>BC
Conductive:BC>AC
DixHallpike maneuver
 Othervestibularsigns
Dynamicvestibularimbalance
Headthrusttest
Peripheralvestibularlesion
Headshakingvisualacuity
Headshakingnystagmus
Calorictest:COWS
 Diagnositic test
Magneticresonanceimaging
Forpossiblecentrallesion
Electronystagmography (ENG)
Vestibularevokedmyogenic potentials(VEMPs)
Audiometry
Brainstemauditoryevokedpotentials(BAEPs)
(Auditorybrainstemresponse,ABR)
 Diagnositic test
Magneticresonanceimaging
Forpossiblecentrallesion
Electronystagmography (ENG)
Whensymptomspersistent
Vestibularevokedmyogenic potentials(VEMPs)
Superiorcannal dehiscencesyndrome
Audiometry
Cochlearfromretrocochlear
Brainstemauditoryevokedpotentials(BAEPs)
(Auditorybrainstemresponse,ABR)
Foracousticneuroma
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