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Vertigo David Clark, DO
Oregon Neurology Associates
Springfield, OR
44F vertigo, nausea &
vomiting
Unidirectional Nystagmus
44F vertigo, nausea &
vomiting
Impaired VOR Gain to the right
Vertigo
• History
• Anatomy/Physiology
• Horses
• Zebras
• Acute management
The Dizzy Bubble
Vertigo
Sleep
Disorder Gait
imbalance
Medication
Effect
Psychiatric
Depression
Anxiety
Panic Anemia
Hypertension
Hypo/hypergl
ycemia
Orthostatic
hypotension
Patient may have
difficulty articulating
their experience clearly
History Tips
• Quality of symptom not very helpful
• Dizzy, Vertigo, Light headed
• Symptom duration helps narrow DDx
• Associated symptoms helpful
• Nausea
• Tinnitus
• Diplopia
• Focal neurologic deficits
Differential by
Symptom Duration
Seconds Minutes Hours Days--Constant
Ischemic (TIA,Stroke)
BPPV**
Migraine
Vestibular
Neuritis
Demyelinating
Menieres
Mass lesion
Perilymphatic
fistula
SSCC dehiscence
**BPPV may be perceived as lasting hours-days
Peripheral vs. Central
Tonic firing from each peripheral
vestibular apparatus
Tonic firing from each
peripheral vestibular apparatus
Pathophysiology of vestibular symptoms and signs: The clinical examination,
DS Zee Neurology Continuum Aug 2006 pg 18
Tonic firing from each peripheral
vestibular apparatus
Asymmetry of the tonic firing tells
the brain there’s movement
Tonic firing from each
peripheral vestibular apparatus
Lesion or overaction
(BPPV) of the peripheral
vestibular aparatus or its
central connections
creates asymmetry of
tonic input and the
sensation of movement
BPPV
~3% population
• Vertigo lasts seconds to
minutes
• Provoked by head rotation
• Roll over in bed
• Look over shoulder
• Nausea/Vomiting
• Queasy for hours in
between
85-90%
Dix Hallpike
Semin Neurol. 2009;29(5):500-508.
Dix-
Hallpike
and Epley
(Steps 1-5)
Semin Neurol. 2009;29(5):500-508.
Diagnosis
and
treatment for
Right
Posterior
Canal BPPV
Epley
Video
Semont For Right posterior canal BPPV
Semin Neurol. 2009;29(5):500-508.
BPPV
• No central mimics of DH nystagmus
• Surgery
• Avoid chronic vestibular suppressants
Vestibular
Neuritis
• Unidirectional
nystagmus
• VOR Gain
• Steroids and
antivirals
VOR Gain Neurology 2011;76;e71
Vestibular Nystagmus
Vestibular neuritis
Slow Phase
Menieres
• Vertigo lasting minutes to hours
• Unilateral aural fullness and
tinnitus
• Over time, low frequency
sensorineural hearing loss
• Treat: diuretics, +/- steroids
• Intractable: intratympanic
gentamycin, surgery
Migrainous Vertigo,
~1% population
1. History of Migraine
2. ≥1 migraine symptom during ≥2 episodes of vertigo
1. HA
2. Photophobia
3. Phonophobia
4. Visual aura
3. No better explanation for vertigo
4. Treat migraine
MS
Diplopia
and
vertigo
Lung
adenocarcinoma
metastasis
Visually mediated dizziness
Post concussive
Migraine
Prior vertigo
Vestibular Schanomma
Superior semicircular canal
dehiscence Valsalva induced vertigo
Perilymphatic fistula
NEJM 366;4
Perilymphatic fistula Test
Can also see Tulio phenomenon
Vertebral artery
dissection and
cerebellar infarct
Bilateral Vestibular Loss
• Etiologies
• Aminoglycosides
• Irradiation
• Paraneoplastic
• Idiopathic
• B/L VOR gain
• Dynamic Visual Acuity
• Can’t read and walk
• No vertigo if symmetric
Static acuity
20/20
Dynamic acuity
20/100
Bilateral Vestibular Loss
• CANVAS
• Cerebellar ataxia
• Neuropathy
• Vestibular areflexia
Visual dizziness
Tardive dizziness following
lesion to Mollaret’s Triangle Red
Nucleus
Inferior
Olive
Dentate
Distinguishing central from peripheral
Peripheral
– Head impulse test: Abnormal
– Unidirectional nystagmus
– No vertical misalignment
Central
– Head Impulse test: Normal
– Alternating nystgmus
– Skew deviation
Skew video
Take home
• Historical keys
• Exam tools
• Dix-Hallpike
• Head impulse test
• Perilymphatic fistula test
• Valsalva
• Epley
• Differentiating central from peripheral vertigo in the acute setting
Questions
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