DIAGNOSIS AND MANAGEMENT OF VERTIGO

Sri Sutarni S
Department Of Neurology Faculty of Medicine GMU/Sardjito General Hospital Jogjakarta

INTRODUCTION
Vertigo:
Common chief complaint Symptom of multiple diseases 40% all American for Dizziness

A. General medical

C. Otological

1. Haematological
Anaemia, Hyperviscosity, Miscellaneous 2. Cardiovascular Postural hypotension

1. Menieres disease
2. Post-traumatic syndrome 3. Positional nystagmus 4. Vestibular neuronitis

Carotid sinus syndrome

5. Infection
6. Otosclerosis and Pagets disease 7. Vascular accidents 8. Tumours 9. Auto-immune disorders 10. Drug intoxication D. Miscellaneous 1. Ocular 2. Cervical

Causes of

Dysrhythmia Mechanical dysfunction 3. Metabolic Hypoglycaemia Hyperventilation B. Neurological 1. Supratentorial Epilepsy, Syncope, Psychogenic

vertigo

2. Infratentorial
Multiple sclerosis, Ischaemia Infective disorders Degenerative disorders

3. Multisensory dizziness syndrome

Tumours
Foramen magnum abnormalities

DIFFERENTIAL DIAGNOSIS
1. Vertigo Dizzy Vomitus Disequilibrium 2. Syncope Absence Light headaches Nausea Visual disturbances Unconsciousness Low blood pressure Postural Hypotension ECG deviation < Doppler

3. Epilepsy: Aura Unconsciousness EEG Head CT Scan

DIFFERENTIAL DIAGNOSIS

The Type of Vertigo

Central Peripheral Mixed type

Gold Standard?

Anamnesis Observation

Diagnosis

DIAGNOSIS OF VERTIGO
Anamnesis Therapy (+) Peripheral > Central Central Risk Factors

ALGORITHM to DIAGNOSE AND MANAGE OF VERTIGO

Full history and examination
Medical Investigation Neuro-otologic invertigation Neurologic Investigation

Peripheral vertigo

Central Vertigo

Mixed Type Vertigo

Medical Treatment of Acute Attack

Supportive Symptomatic Causative

Surgery (?) (+ / - )

Failure

Physical exercise Regimens of maneuvers Psychological support Vestibular sedatives

Medical Treatment of Chronic Recurrent Vertigo

Peripheral or Central Causes?

Peripheral Labyrinth or vestibular nerve dysfunction Recurrent Nystagmus-horizontal Position change Moderate to severe vertigo Central Cerebellum or brain stem dysfunction Continuous Nystagmus-vertical Non-positional Mild vertigo

Differential Diagnosis and Management for the Chiropractor,

DIAGNOSTIC ALGORITHM FOR THE DIZZI PATIENT

Vertigo Episodic positional Episodic Non-positional Non-episodic Non-positional

Schimp D. A diagnostic algorithm for the dizzy patient Chiropractic

1
Episodic positional

Benign positional

Cervicogenic

Vertebobasilar ischemia

sudden

sudden

gradual

Fades 30-60 seconds

persists

progression

2
Episodic non-positional Menieres Perilymph fistula

3
Non-episodic Non-positional vertigo Labyrinthitis Acoustic neuroma Cerebral hemorrhage

BPPV Benign Recurrent of Vertigo

BPPV:
Acute Vertigo Benign Movement / provocation of head Horizontal nystagmus

Benign Recurrent of Vertigo

Acute Several minutes hours Static of disequilibrium

Vertebrobasilar TIA Precipitating Factors

Vertebrobasilar TIA:
Hearing loss (+) / (-) Nystagmus (+) Diplopia Cerebellar Disturbances MRI of the brain, brainstem and angiography

Precipitating factors of vertigo:

Motion sickness Morning sickness

Diagram - interaction of autonomic, psychological, and vestibular symptoms

EXAMINATION
Blood laboratory not specific Neurological examination Radiology examination BERA (Brainstem Evoked Response Auditory) Audiometry ?

NEUROLOGICAL EXAMINATION
Within normal limits Anamnesis >> important Acute vertigo emergency case Peripheral vertigo acute onset, horizontal nystagmus Central vertigo Risk factors(?), vertical / rotational nystagmus

NEUROLOGICAL EXAMINATION (cont)

Provocation test to increase vertigo symptoms : Hallpike Dick maneuver Examination of: 1. Consciousness 2. Cranial Nerve 3. Motoric 4. Sensory 5. Cerebellar functions

SPECIFIC EXAMINATION FOR VERTIGO

Heart rate and rhythm of the heart Palpation on the Carotid artery Auscultation of the Carotid artery Romberg test Tandem gait

ANOTHER STIMULATION FOR VERTIGO

Orthostatic hypotension Valsava maneuver Rotational of the head Nylen Barani Test Hallpike-Dick Maneuver Caloric test Neuro-ophtalmology examination Otology Examination Head Ct Scan / MRI Audiometry BERA

Hallpike Dick Maneuver

TREATMENT
Supportive Symptomatic Causative Operative

Onset of Therapy: Acute Chronic

Acute Phase
1. Anti Cholinergic
Sulfas atropine 0,4 mg im Scopolamine 0,5 mg i.v; repeated every 3 hours

2. Sympathycomimetic
Epidame 1,5 mg i.v repeated every 30 minutes

Inhibition of Vestibular Nucleus

1.

Anti histamine :
Diphenhidramine 1,5 mg im/ p.o repeated every 2 hours Dimenhidrinate 50-100 mg every 8 hours Flunarizine

2.

Sedative :
Phenobarbital 10-30 mg/ 6 hours Diazepam 5-10 mg Chlorpromazine (CPZ) 25 mg

CAUSATIVE THERAPHY
1.

Vertebrobasilar insufficiency
Anti platelet aggregation Vasodilators Flunarizine

2.

Epilepsy
Phenitoine Carbamazepine

3.

Migraine
Ergotamine Flunarizine

OPERATIVE THERAPHY
Tumors Cervical spondylosis Basilar impression

CONCLUSION
Incidence of vertigo : 10-15% Uncomfortable but not fatal Differential diagnosis of Central and peripheral vertigo treatment Maneuver to precipitate vertigo Recurrent must be prevent Etiology and symptomatic treatment