A clinical approach to A clinical approach to the the
diagnosis of vertigodiagnosis of vertigo
John WaterstonJohn Waterston
Alfred Hospital Alfred Hospital
MelbourneMelbourne
Traditional neurological Traditional neurological diagnosisdiagnosis►Localisation of lesion site Localisation of lesion site
““wherewhere””
►Identification of pathology Identification of pathology ““whatwhat””
The vast majority of cases of vertigo are due to peripheral causes or benign central conditions (migraine).
HOWEVER
Is it vertigo?Is it vertigo?
►Definition: an illusion of motionDefinition: an illusion of motion Spinning, dropping, tilting, fallingSpinning, dropping, tilting, falling ““something moving inside my head”something moving inside my head”
►Usually aggravated by head movementsUsually aggravated by head movements►Differential diagnosis largeDifferential diagnosis large
Anxiety and hyperventilationAnxiety and hyperventilation Postural hypotensionPostural hypotension
Syndrome approachSyndrome approach
►Acute, chronic or recurrentAcute, chronic or recurrent
►Spontaneous or (head) Spontaneous or (head) motion-inducedmotion-induced
4 key syndromes4 key syndromes
►Acute vestibulopathyAcute vestibulopathy►Recurrent vestibulopathyRecurrent vestibulopathy►Motion-induced vertigoMotion-induced vertigo►DisequilibriumDisequilibrium
} spontaneous
1. 1. Acute vestibulopathyAcute vestibulopathy
Vestibular neuritis
Stroke (PICA, AICA) Perilymph fistula
Trauma
Vestibular neuritis (neuronitis)Vestibular neuritis (neuronitis)
►A common cause of acute vertigoA common cause of acute vertigo►Many cases thought to be due to Many cases thought to be due to
reactivation of herpes simplex Ireactivation of herpes simplex I►Similar pathogenesis to Bell’s palsySimilar pathogenesis to Bell’s palsy►Acute vertigo, unidirectional nystagmusAcute vertigo, unidirectional nystagmus
Normal VOR
Abnormal VOR
Halmagyi & Curthoys, 1988.
Management: Management: Shupak et al, Otology & Neurotology. 2008. 29:368-374.Shupak et al, Otology & Neurotology. 2008. 29:368-374.Strupp et al, NEJM. 2004. 351:354-361.Strupp et al, NEJM. 2004. 351:354-361.
►Prednisolone aids clinical and laboratory Prednisolone aids clinical and laboratory recoveryrecovery 1 mg/kg for 5 days, followed by reducing dose 1 mg/kg for 5 days, followed by reducing dose
over next 15 days.over next 15 days.
►Valacyclovir ineffectiveValacyclovir ineffective►Other treatmentOther treatment
prochlorperazine, promethazineprochlorperazine, promethazine
HINTS to Diagnose Stroke in the Acute
Vestibular Syndrome
Three-Step Bedside Oculomotor Examination More Sensitive Than Early
MRI Diffusion-Weighted Imaging
Jorge C. Kattah, MD; Arun V. Talkad, MD; David Z. Wang, DO;Yu-Hsiang Hsieh, PhD, MS; David E. Newman-Toker, MD, PhD
Stroke 2009;40;3504-3510
HINTS (high stroke risk)HINTS (high stroke risk)
►HHead ead ►IImpulse (normal)mpulse (normal)
►NNystagmus (direction changing)ystagmus (direction changing)
►TTest ofest of►SSkew deviation (present)kew deviation (present)
Benign HINTS examination result at thebedside “rules out” stroke better than a negative MRI with DWI in the first 24 to 48 hours after symptom onsetThe sensitivity of early MRI with DWI for lateral medullary or pontine infarction was lower than that of the bedside examination (72% versus 100%)
2. 2. Recurrent vestibulopathyRecurrent vestibulopathy
Migraine
Meniere’s disease Vertebro-basilar insufficiency
Vestibular paroxysmia
Focal epilepsy
Episodic ataxia
3. 3. Motion induced vertigoMotion induced vertigoUncompensated peripheral lesion
Benign positional vertigo Migraine
Cerebellar disease
Cervical vertigo
Usually respond to physical treatment modalities
Benign positional vertigoBenign positional vertigo
►~25% of cases of vertigo.~25% of cases of vertigo.►May be primary or secondary.May be primary or secondary.►Short-lived bouts of vertigo.Short-lived bouts of vertigo.►Positional featuresPositional features
in bed, head extension (in bed, head extension (““top shelf vertigotop shelf vertigo””), ), bending.bending.
►Usually curable!Usually curable!
Mechanism of benign positional vertigo
DiagnosisDiagnosis
►Must see nystagmus with vertigoMust see nystagmus with vertigo►Patients with other vestibular disorders will Patients with other vestibular disorders will
often feel dizzy during the Hallpike often feel dizzy during the Hallpike manoeuvremanoeuvre
►Spontaneous or central nystagmus may be Spontaneous or central nystagmus may be more prominent during positional testingmore prominent during positional testing
Epley manoeuvre (right sided BPV)
Semont manoeuvre for right sided BPV
Brandt-Daroff exercises for management of benignpositional vertigo (posterior canal)
Acta Otolaryngol. 1980;106:484-485
4. 4. DisequilibriumDisequilibrium► CNSCNS
cerebellar diseasecerebellar disease normal pressure hydrocephalusnormal pressure hydrocephalus multi infarct statemulti infarct state
► Proprioceptive lossProprioceptive loss spinal diseasespinal disease peripheral neuropathyperipheral neuropathy
► OtherOther bilateral vestibular hypofunctionbilateral vestibular hypofunction ageingageing hypothyroidismhypothyroidism multi-sensory dizziness/disequilibriummulti-sensory dizziness/disequilibrium (visual, vestibular, (visual, vestibular,
cervical spine, neuropathy, orthopaedic)cervical spine, neuropathy, orthopaedic)
““Red FlagsRed Flags””►Other neurological signsOther neurological signs►Ataxia out of proportion to vertigoAtaxia out of proportion to vertigo►Nystagmus out of proportion to vertigoNystagmus out of proportion to vertigo►Central nystagmusCentral nystagmus
vertical, gaze evoked, dissociated, acquired vertical, gaze evoked, dissociated, acquired pendularpendular
►Central eye movement abnormalitiesCentral eye movement abnormalities broken pursuit , gaze palsy, dysmetric or slow broken pursuit , gaze palsy, dysmetric or slow
saccades, skew deviationsaccades, skew deviation
SummarySummary►Learn to differentiate between spontaneous Learn to differentiate between spontaneous
and (head) motion induced vertigoand (head) motion induced vertigo►Think of migraine, particularly in the younger Think of migraine, particularly in the younger
patient presenting with unexplained recurrent patient presenting with unexplained recurrent vertigo.vertigo.
►Vertebro-basilar ischaemia is a rare diagnosisVertebro-basilar ischaemia is a rare diagnosis►Examine the eye movements carefullyExamine the eye movements carefully►Do a Hallpike test (except when there is Do a Hallpike test (except when there is
obvious spontaneous nystagmus).obvious spontaneous nystagmus).