Vertigo

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Vertigo from a neurologists point of view

• Tung-Hua Chiang M.D.
• Department of Neurology
• Cheng-Ching General Hospital

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• Dizziness and other sensations of imbalance are,
  along with headache, back pain, the most frequent
  complaints among medical outpatients (Kroenke and
  Mangelsdorff).
• For the most part they are benign, but always
  there is the possibility that they signal the
  presence of an important neurologic disorder.

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• Diagnosis of the underlying disease demands that
  the complaint of dizziness be analyzed correctly
  - the nature of the disturbance of function being
  determined first, and then its anatomic
  localization

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Vertigo should be correctly defined

• Dizziness a feeling of rotation or whirling
  as well as nonrotatory swaying, weakness,
  faintness, light-headedness, or unsteadiness.
• Vertigo subjective and objective illusions of
  motion

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Mechanisms responsible for the maintenance of a
balanced posture

• Continuous afferent impulses from the eyes,
  labyrinths, muscles, and joints
• The adaptive movements necessary to maintain
  equilibrium are carried out - at a reflex level.

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Afferent impulses (1)

• Visual impulses from the retinas and possibly
  proprioceptive impulses from the ocular muscles.

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Afferent impulses (2)

• Impulses from the labyrinths, the three
  semicircular canals sense angular acceleration of
  the head, and the saccular and utricular maculae
  sense linear acceleration and gravity
• Vestibulo-ocular reflex - stabilizes the eyes
• Vestibulo-spinal reflex - stabilizes the position
  of the head and body

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Afferent impulses (3)

• Impulses from the proprioceptors of the joints
  and muscles, which are essential to all reflex,
  postural, and volitional movements.

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• All connected with cerebellum and certain
  ganglionic centers and pathways in the brainstem,
  particularly the vestibular nuclei, and, via the
  medial longitudinal fasciculi, with the red and
  ocular motor nuclei.
• Any disease that disrupts these neural mechanisms
  may give rise to vertigo

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• Cerebral cortical lesion
• vertigo may constitute the aura of an epileptic
  seizure
• electrical stimulation of the cerebral cortex
  (posterolateral aspects of the temporal lobe,
  inferior parietal lobule, adjacent to the sylvian
  fissure) may evoke intense vertigo

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• Vertiginous epilepsy vs Vestibulogenic seizures
• Vestibulogenic seizures an excessive vestibular
  discharge serves as the stimulus for a seizure -
  a rare form of reflex epilepsy

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• Ocular motor disorders
• abrupt onset of ophthalmoplegia with diplopia - a
  source of spatial disorientation and brief
  sensations of vertigo (maximal when looks in
  the direction of action of the paralyzed muscle
  receipt of two conflicting visual images)

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• Cerebellum
• depend on which part of this structure is
  involved
• large, destructive processes in the cerebellar
  hemispheres and vermis may cause no vertigo
• lesions involving the territory of the medial
  branch of the PICA may cause intense vertigo,
  indistinguishable from that due to labyrinthine
  disorder.

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• Infarction extended to the midline and involved
  the flocculonodular lobe falling toward the
  side of the lesion nystagmus was present on gaze
  to each side but was more prominent on gaze to
  the side of the infarct

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• Labyrinthine disease
• unidirectional nystagmus to the side opposite the
  impaired labyrinth and swaying or falling toward
  the involved side, direction of the nystagmus is
  opposite to that of the falling and past pointing

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• Cervical vertigo
• Biemond and DeJong
• originating in the upper cervical roots and the
  muscles and ligaments that they innervate
• Spasm of the cervical muscles, trauma to the
  neck, and irritation of the upper cervical
  sensory roots are said to produce asymmetrical
  spinovestibular stimulation and thus to evoke
  nystagmus and prolonged vertigo, and
  disequilibrium.

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• Downbeat nystagmus, vertigo and postural
  instability have been observed with paramedian
  lesions at the craniocervical junction.
• Upbeat nystagmus with oscillopsia and vertigo has
  been traced to two separate brainstem lesions
  one in the perihypoglossal nuclei and the other
  in the pontomesencephalic tegmentum (Brandt)

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• Cervical vertigo has also been attributed to VBI
• Occasionally, vertigo lasting a few minutes
  occurs as a prelude to a basilar migraine
  headache (Grad and Baloh).

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Meniere disease

• Recurrent attacks of vertigo associated with
  fluctuating tinnitus and deafness.
• Meniere disease affects the sexes about equally
  and has its onset most frequently in the fifth
  decade of life, although it may begin earlier or
  later.
• Usually sporadic, but rare hereditary forms, both
  AD AR

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• The main pathologic change increase in the
  volume of endolymph and distention of the
  endolymphatic system (endolymphatic hydrops)
• Paroxysmal attacks of vertigo ruptures of the
  membranous labyrinth and a dumping of
  potassium-containing endolymph into the
  perilymph, which has a paralyzing effect on
  vestibular nerve fibers and leads to degeneration
  of the delicate cochlear hair cells

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• A small proportion of patients with Meniere
  disease experience sudden, violent falling
  attacks "otolithic catastrophe of Tumarkin,"
  deformation of the otolithic membrane of the
  utricle and saccule. Consciousness is not lost
• An initial attack must be distinguished from
  other types of drop attacks, occurrence of more
  typical vertiginous attacks with deafness and
  tinnitus, clarify the diagnosis.

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• The hearing loss in Meniere disease usually
  precedes the first attack of vertigo
• There is frequently a decrement in hearing with
  each attack hearing may improve after a few
  hours, but later the loss becomes irreversible
• Early low tones Later high tones

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• The attacks of vertigo usually cease when the
  hearing loss is complete.
• Sensorineural type of deafness

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• During an acute attack of Meniere disease, rest
  in bed is the most effective treatment
• Destruction of the labyrinth should be considered
  only in patients with strictly unilateral disease
  and complete or nearly complete loss of hearing.

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• Bilateral disease or significant retention of
  hearing, the vestibular portion of the eighth
  nerve can be sectioned or decompressed (by
  separating the nerve from an aberrant vessel).
• Endolymphatic-subarachnoid shunt is the operation
  favored by some surgeons

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Vestibular Neuronitis (Neuropathy)

• Originally by Dix and Hallpike
• Disturbance of vestibular function, paroxysmal
  and usually single attack of vertigo and absence
  of tinnitus and deafness.

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• Mainly in young to middle-aged adults, equal sex.
  
• Antecedent URI
• Examination discloses vestibular paresis on one
  side
• Nystagmus (quick component) and sense of body
  motion are to the opposite side, whereas falling
  and past pointing are to the side of the lesion.
• Auditory function is normal.

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• A benign disorder.
• The severe vertigo subside in several days, but
  lesser degrees of these symptoms, made worse by
  rapid movements of the head, may persist for
  several weeks.
• In some patients there has been a recurrence
  months or years later.

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• Primarily affected the superior part of the
  vestibular nerve trunk, which was observed to
  show degenerative changes
• The cause is uncertain, may be a viral infection,
  many neurologists prefer the term vestibular
  neuropathy.

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Other Paroxysmal Vertigo

• A single abrupt attack of severe vertigo, nausea,
  and vomiting without tinnitus or hearing loss,
  with permanent ablation of labyrinthine function
  on one side -gt suggested occlusion of the
  labyrinthine division of the internal auditory
  artery Labyrinthine hemorrhage has been
  demonstrated by MRI in some of these patients.

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• In childhood good health, sudden onset of
  brief vertigo, pallor, sweating, and immobility,
  and occasionally vomiting and nystagmus.
• Recurrent but tend to cease spontaneously after a
  period of several months or years
• Impairment or loss of vestibular function,
  bilateral or unilateral, frequently persisting
  after the attacks have ceased. Cochlear function
  is unimpaired.
• Unknown pathologic basis

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• Young adults in which a nonsyphilitic
  interstitial keratitis is associated with
  vertigo, tinnitus, nystagmus, and rapidly
  progressive deafness.
• The prognosis for vision is good, but the
  deafness and loss of vestibular function are
  usually permanent.
• Unknown cause and pathogenesis
• Half of the patients later develop aortic
  insufficiency or a systemic vasculitis that
  resembles polyarteritis nodosa.

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• There are many other causes of aural vertigo,
  such as purulent labyrinthitis complicating
  meningitis, serous labyrinthitis due to infection
  of the middle ear, "toxic labyrinthitis" due to
  intoxication with alcohol, quinine, or
  salicylates, motion sickness, and hemorrhage into
  the inner ear.

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• Head trauma, cerebral concussion or whiplash
  injury, vertigo due to loosening or dislodgement
  of the otoconia in the otoliths.

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• Thanks!