Neurological lectures...Vertigo http://yassermetwally.com http://yassermetwally.net

1. Vertigo
Professor Yasser Metwally

2. What could be reffered to as
„dizziness” by the patient?
• Rotational vertigo
• Sense of instability
• Ataxia of gait
• Disturbance of vision
• Loss of contact with surroundings
• Nausea
• Loss of memory
• Loss of confidence
• Epileptic convulsion

3. Development of vertigo
Afferent
Visual
Proprioceptive
Vestibular
CNS
Efferent
Oculomotor
Dizziness
Sceletal muscles
Vegetative

4. What should be considered
dizziness by medical personnel?
1. Vertigo
• A sense of feeling the environment moving when
it does not. Persists in all positions. Aggravated
by head movement.
2. Dysequilibrium
• A feeling of unsteadiness or insecurity without
rotation. Standing and walking are difficult.
3. Light headedness
• Swimming, floating, giddy or swaying sensation
in the head or in the room.

5. Questions to be asked (taking the
history)
1. Anamnesis
• What the patient means by vertigo
• Time of onset
• Temporal pattern
• Associated sings and symptoms (tinnitus,
hearing loss, headache, double vision,
numbness, difficulty of swallowing)
• Precipitating, aggravating and relieving factors
• If episodic: sequence of events, activity at
onset, aura, severity, amnesia etc.

6. Examination of the patient with
vertigo
2. Physical examination
• Spontaneous nystagmus
• Positional nystagmus
• Optokinetic nystagmus
• Posture and balance control
• Romberg’s test
• Blind walking, Untenberger
• Bárány’s test
• Stimulations of labyrinth
• Caloric test (cold, warm water)
• Rotational test

7. In case of vertigo
No sponteous nystagmus Sponteous nystagmus
Posture and balance control negative Posture and balance control positive
Nausea Sweating, tachycardia Nausea, vomiting, sweating, anxiety
vomiting
GI disorder Chest pain Anxiety „Harmonic” „Dysharmonic”
vestibular sy vestibular sy
Internal Angina, MI Loss of hearing, Numbness,
medicine tinnitus double vision,
dysarthria
Cardiology Psychiatry Vestibular Brainstem infarct
neuronitis,
Meniére disease
Otology Neurology

8. Differentiating peripheral and central
vestibular lesion
1. Peripheral
• „harmonic” vestibular syndrome
• Falls in Romberg position and deviates during walking
with closed eyes to the side of the slow component of
nystagmus
• Direction of nystagmus does not change with direction
of gaze (I. II. III. degree!)
• Nystagmus can be horizontal, or rotational, but never
vertical
• Nystagmus occurs after a brief latent period
• Severe rotating, whirling vertigo
• Symptoms aggravate after moving of the head position
• Severe vegetative sings (vomiting, sweating)
• Fear of death in severe cases
• Caloric response decreased on side of lesion

9. Differentiating peripheral and central
vestibular lesion
2. Central
• „dysharmonic”vestibular syndrome (rarely harmonic!!)
• Falls in Romberg position and deviates during
walking with closed eyes to the side of the fast
component of nystagmus
• Direction of nystagmus might change with
direction of gaze
• If nystagmus is vertical or dissociated, it cannot
be peripheral
• Vertigo is usually not whirling
• Vegetativ signs are less severe if any
• Associated neurological signs: diplopia,
dysarthria, dysphagia, numbness, paresis, ataxia.

10. Examination of the patient with
vertigo
3. Laboratory examinations and imaging
• Electronystagmography
• Video-oculography
• Audiometry
• BAEP
• CT
• MRI

11. Common causes of vertigo
1. Peripheral
• Physiological (motion sickness)
• Benign paroxysmal positional vertigo
• Vestibular neuronitis
• Labyrinthitis
• Meniére disease
• Perilymph fistula
2. Central
• Brainstem TIA/infarct
• Posterior fossa tumors
• Multiple sclerosis
• Syringobulbia
• Arnold - Chiari deformity
• Temporal lobe epilepsy
• Basilar migraine
3. Other
• Cardiac, GI, psycogen, toxins, medications, anemia,
hypotension

12. Duration of vertigo
Time Peripheral Central
Seconds BPPV VB-TIA, aura of
epilepsy
Minutes perilymph fistula VB-TIA, aura of
migraine
(Half) hours Meniére disease basilar migraine
Days vestibular neuronitis VB stroke
labyrinthitis
Weeks, Month acustic neurinoma, multiple sclerosis
drug toxicity cerebellar
degenerations

13. Peripheral types of vertigo
1. Benign paroxysmal positional vertigo
• Most often
• Lasts less than 30 seconds
• Occurs only with a change in head position
• Nystagmus is transient, fatigable and its direction is
constant
• Reason: otoconia
• Positional vertigo is not always benign and not
always vestibular in origin!

14. Left Right
-
AC AC
HC HC
PC PC
+

15. BPPV diagnosis: Dix-Hallpike
manoeuvre

16. BPPV: therapy
• Medications not necessary
• Position training
Semont Brandt-Daroff

17. 2. Vestibular neuronitis
• Sudden severe vertigo
• „harmonic” vestibular syndrome
• No cochlear symptoms (tinnitus, hearing
loss)
• Reduced caloric reaction on affected side
• Recurrent attacks
• Lasts for several days

18. 2. Vestibular neuronitis
Reason: viral infection, vascular or unknown origin
Therapy:
1-3. days. bedrest, vestibular suppressants (diazepam,
clonazepam) antiemetics, vitamin B
antiviral agents (?), corticosteriods(?)
From 3. day: position training
3. Labyrinthitis
As vestibular neuronitis, but there are also cochlear
symptoms.

19. 4. Menière disease
• Recurrent attacks in clusters
• Tinnitus
• Progressive hearing loss, unilateral first
• Vertigo for at least 5 to 30 min
• Vegetative signs
• Sense of pressure in the ear
• Distorsion of sounds
• Sensitivity to noises

20. 4. Menière disease
• Pathogenesis: endolymphatic hydrops
• Therapy: salt free diet, nicotin, alcohol-
withdrawal, acetazolamide, betahistine

21. 5. Perilymphatic fistula
• Fistula of the round window
• Hearing loss with or without vertigo
• Sudden changes of pressure in the middle
ear (weight lifting, diving, nose blowing)

22. Drug toxicity
• Aminoglycoside antibiotics
• Anticonvulsants
• Salycilates
• Alcohol
• Sedatives
• Antihistamines
• Antidepressants

23. Other causes of vertigo
• Cervical spondylosis
• Sensory deprivation (neuropathy, visual
impairment)
• Anemia
• Hypoglycaemia
• Orthostatic hypotension
• Hyperventilation