Central Neurogenic Central Neurogenic

VertigoVertigo

Vertigo in Neuro ClinicVertigo in Neuro Clinic

June 99 to May 2000 Total no of Neuro cases seen: 2456 Total no of vertigo cases seen: 248 Male : Female 150: 106 < 10 years 6 10 – 20 years 4 20 – 40 years 112 40 – 60 years 74 > 60 years 48

Is It Central Vertigo?Is It Central Vertigo?

Associated symptomsAssociated symptoms

Central : diplopia, dysarthria, dysphagia,

perioral numbness, one sided weakness

or ataxia, headache (occipital)

Peripheral: Hearing loss, tinnitus,

Vertigo Central/peripheral ?Vertigo Central/peripheral ?

Symptom Peripheral Central

Hallucinationof movement

Definite Less definite

Onset Paroxysmal Acute

Intensity Severe Moderate

Duration Short Long

Postural frequent Seldom

Vertigo Central/peripheral? Vertigo Central/peripheral?

Symptoms Peripheral Central Nystagmus Present May present ANS Frequent Less frequent Tinnitus Frequent Seldom Deafness Frequent Seldom Consciousness Preserved May loss Neurologic sign

Absent Present

Vertigo in ChildhoodVertigo in Childhood

Neurological deficitNeurological deficit Isolated Isolated

Tumor MigraineEpilepsy

Migraine and VertigoMigraine and Vertigo

Most common cause of vertigo in children 34.7% Basilar migraine and Migraine equivalents as

benign paroxysmal vertigo Migraine and benign positional vertigo may

coexist (migraine 3 times in BPV) 32% Miigraineurs had higher prevalence central and

peripheral vestibular dysfunction compared to non-migraineurs

Respond to anti migraine medication

Basilar migraineBasilar migraine

Bickerstaff in 1961

Vertigo with brain stem symptoms

followed by headache

Due to basilar artery vasoconstriction

followed by vasodilatation

Recently central mechanism postulated

Benign paroxysmal vertigo in Benign paroxysmal vertigo in childhood.childhood.

Vertigo of sudden onset lasting a few minutes and in extreme cases several hours or even up to 2 days.

Autonomic symptomsnystagmusConsciousness is not impaired.Frequency varies weeks to months

Episodic vertigo related to migraine Episodic vertigo related to migraine vestibular migraine?vestibular migraine?

Onset : at any age, peak fourth decade in men and a "plateau" between the third and fifth decades in women.

Duration: Few seconds to several hours

78% Mono-symptomatic Vertigo

16% audio-vestibular 32% not associated with

headache

In the symptom-free interval – 66% of the patients showed

mild central ocular motor signs such as vertical (48%) and/or horizontal (22%) saccadic pursuit, gaze-evoked nystagmus (27%), moderate positional nystagmus (11%), and spontaneous nystagmus (11%).

52% with other migraine Nervenarzt 1993

Feb;64(2):121-6

Epileptic vertigoEpileptic vertigo

Vertigo is common as aura of an

epileptic attack

Isolated recurrent vertigo is rare

Usually last for few seconds

EEG shows temporal spikes

Vertigo in AdultVertigo in Adult

Hearing lossHearing loss IsolatedIsolated

Meniere'sMeniere's

CA MassCA MassLabyrinthitisLabyrinthitisVestibular Vestibular NeuronitisNeuronitis

Benign Benign PositionalPositional

CP angle tumorCP angle tumor

Rarely present solely with episodic vertigo.Vertigo occurs in approximately 20%, but a

symptom of imbalance or dis-equilibration is more common

The most common symptoms associated progressive hearing loss and tinnitus.

Look for neurological signs such as a depressed corneal reflex.

The diagnostic value of imaging the The diagnostic value of imaging the patient with dizziness. A Bayesian patient with dizziness. A Bayesian

approach.approach.

Dizziness : 0.0004 or 1 in 2500 Isolated dizziness without hearing loss: .000107

or 1 in 9307 Dizziness with asymmetric hearing loss:

0.00156 or 1 in 638

Clin Otolaryngol 1996 Feb;21(1):80-3

Imaging in Dizziness for CAMImaging in Dizziness for CAM

Progressive hearing loss with abnormal speech reception

thresholds probably warrants a magnetic resonance imaging scan of the internal auditory

canals.

Bilateral loss of vestibular function: Bilateral loss of vestibular function: clinical findings in 53 patients.clinical findings in 53 patients.

39% had associated neurological disease

13% had a progressive cerebellar syndrome

9% cranial or peripheral neuropathies with hearing loss

11% had hearing loss secondary to meningitis

6% had other neurological disorders.

17% had Gentamicin ototoxicity

9% autoimmune disease 13% Otological or

neoplastic disease 21% Idiopathic BVF -

characterised by paroxysmal vertigo and/or oscillopsia, but no abnormal clinical signs.

J Laryngol Otol 1998 Feb;112(2):193-5

Vertigo in ElderlyVertigo in Elderly

Neurological deficitNeurological deficit IsolatedIsolated

VascularVascular CervicogenicCervicogenic

Vascular VertigoVascular Vertigo

Vertebrobasilar Insufficiency

Wallenberg’s syndrome

AICA syndrome

Cerebellar infarction

Cerebellar hemorrhage

Lateral medullary syndromeLateral medullary syndrome

Complete syndrome: Vertigo with dysphagia, dysarthria, ipsilateral ataxia and facial anesthesia, Horner's syndrome and contralateral body anesthesia

Incomplete syndrome may present with vertigo followed by subtle Horner. Facial and body hypoesthesia. Needs careful examination.

Small Cerebellar infarction Small Cerebellar infarction

Vertigo, unsteadiness and unidirectional nystagmus – Vestibular neuritis

Vertigo with tinnitus and hearing disturbance – Meniere's disease

Paroxysmal positional vertigo – BPV

Clue to small cerebellar Clue to small cerebellar infarctioninfarction

Transient headache and blurred visionVertigo may disappear but ataxia may

progressElectronystagmography show normal

peripheral apparatus

VBI and VertigoVBI and Vertigo Vertigo is common in VBI Isolated vertigo was thought to rule out VBI in elderly Recently many papers have emphasized isolated recurrent

vertigo as symptom of VBI Ischemia of vestibule by AICA and medial cerebellum by

PICA MRA, Angiography BAER may help In elderly patients with no laboratory evidence of

peripheral vestibulopathy or systemic disease, episodic disequilibration or dizziness may be due to vertebrobasilar disease

Cervicogenic VertigoCervicogenic Vertigo

Abnormal cervical proprioceptive impulse to vestibular apparatus

Associated neck pain and tender points and limitation of neck movements

Improves with limitation of neck movements and aggravated by neck movements

Cervical spondylosis, cervical trauma

Clinical significance of cervical arthropathy in patients with vertigo.

102 Patient examined with 20 Control with vestibular symptoms

No relationship was observed between the degree of cervical spondylosis and vestibular abnormalities

an age dependent microvascular damage may be more likely as an etiological factor for vestibular symptoms in the elderly.

Rev Med Chil 1990 Jun;118(6):657-61

Isolated Vertigo 99-2000Isolated Vertigo 99-2000

Epilepsy 02 Migraine 10 Cervical spondylosis 30 Peripheral unclassified 122 Meniere's 01 BPV 01 CPA Mass 00 VBI 00

Thank youThank you