The Brigham Department of Neurology Martin A. Samuels, M.D., Chairman
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1 The Brigham Department of Neurology, M.D., Chairman Brigham & Women s Hospital, Boston, Massachusetts
2 Dizziness, M.D. Chairman, Department of Neurology Brigham & Women s Hospital Professor of Neurology Harvard Medical School
3 History in the Dizzy Person Take an open-ended history-no suggestions Know the synonyms (e.g. giddy, woozy) Beware of medicalized history (e.g. vertigo) Pace of the illness (acute, subacute, chronic) Listen for neighborhood symptoms Hearing loss, tinnitus suggests peripheral Diplopia, dysarthria suggests central
4 Types of Dizziness Vertigo: illusion or hallucination of motion Near syncope: cerebral hypoperfusion Dysequilibrium: gait disorder Ill-defined lightheadedness: anxiety
5 Epidemiology of Dizziness: More dizziness than dizzy people 1.5 dizzy complaints per dizzy person Half of all dizziness is vertigo Half of all dizziness is divided among: Near syncope Dysequilibrium Ill-defined lightheadedness
6 Causes of Persistent Dizziness in Elderly Patients in Primary Care Ann Fam Med 2010;8:
7 Examination of the Dizzy Person Orthostatic BP and heart rate Hyperventilation /squatting Carotid sinus massage by expert only Hearing testing Pure tone hearing loss Neural hearing loss (air vs bone conduction) Cochlear vs retrocochlear hearing loss (speech discrim) Vestibular testing Spontaneous nystagmus (?alternating) Head impulse test Test for skew (alternate cover refixation) Induced nystagmus (Dix-Hallpike maneuver) Proprioception testing (Romberg test) Cerebellar testing, including gait
8 Dix-Hallpike Maneuver
9 VIII Nerve Anatomy & Physiology Three semicircular ducts (angular acceleration) X,Y,Z planes (roll, yaw and pitch) Utricle and saccule (linear acceleration) Cochlear duct (hearing) Perilymph (extracellular [spinal] fluid) Endolymph (intracellular fluid) End organ is a force transducer obeying F=MA
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14 Pathogenesis of Benign Paroxysmal Positional Vertigo Canalalithiasis is the most common cause Posterior canal is the most likely offender Affected canal becomes gravity sensitive Characteristics of the nystagmus and vertigo Brief latency Tortional in dependent eye Vertical in other eye Transient (less than 60 seconds) Reverses on return to upright posture
15 Canalolithiasis
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21 Repositioning Maneuvers for BPPV All based on the principle of moving the calcium from the semicircular canal back into the utricle from whence it came Methods: Epley Semont Brandt-Daroff exercises
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28 Semont Maneuver
29 Brandt-Daroff Exercises
30 Later Canal BPPV Maneuver
31 Perilymphatic Fistula Rare cause of postional vertigo Perilymph leak at round or oval window Conductive hearing loss may be present Variable history of trauma, often remote Positive fistula test Confirmation with radionuclide study Surgical repair of rent in window may work
32 Superior Canal Dehiscence Noise induced vertigo (Tullio phenomenon) Usually spontaneous, but may be traumatic Oscillopsia is common Usually resolves spontaneously
33 Labrynthitis, Vestibular Neuritis and Cochlear Neuritis Acute vertigo and/or hearing loss May be viral or post-viral Pulsed steroids shorten the course Antiviral agents add no additional benefit Improves substantially in 6-12 weeks
34 Meniere Disease Episodic vertigo and/or hearing loss, usually with prominent tinnitus Over time, hearing deteriorates May be immune mediated Pulse steroids may help acute attacks No good evidence that any treatment works Symptomatic therapy during attacks Diuretics are of questionable value
35 Traumatic Vertigo Usually major trauma with basilar skull fx Vertigo and/or hearing loss with nystagmus Overall good prognosis Substantial improvement in 3-6 months Symptomatic treatment
36 Postconcussion Syndrome Delayed onset symptoms after head trauma Often associated with whiplash symptoms No nystagmus or objective hearing loss Beware of drug induced nystagmus Related to an ulterior motive No medical treatment is effective Return to work and end of litigation are best
37 Vestibulo-cochlear tumors Usually Schwannomas or meningiomas Vestibular Schwannoma is most common Progressive retrocochlear hearing loss Variable and often mild vertigo Tinnitus is not usually prominent Magnetic resonance imaging is very useful Usually treatable with surgery or focal RT
38 Vertebro-Basilar Ischemia Pure vertigo is almost never a symptom of main stem basilar disease, but can be basilar branch or vertebral Listen carefully for neighborhood symptoms (e.g. diplopia, dysarthria) Look carefully for neighborhood signs (e.g. Horner syndrome, facial weakness, ataxia) Always test gait (cerebellar lesions affect gait more than peripheral vestibular ones) HINTS: horizontal head impulse test; fast phase of nystagmus; skew deviations on alternate cover test INFARCT: impulse normal; fast phase alternating; refixation on cover test
39 Migrainous Vertigo Probably quite common About 10% of migrainous attacks include vertigo; more in younger patients About 10% of vertiginous attacks are associated with headache Motion sickness (physiological vertigo) is strongly associated with migraine
40 Near Syncope Pathogenesis: global cerebral hypoperfusion Usually orthostatic Inadequate volume or failure to adequately vasoconstrict in the upright posture Exercise induced is worrisome for cardiac cause Long-term loop recorders of HR and BP helpful Common causes: Neurally induced (bradycardic; vasodepressor) Volume depletion Cerebral vasoconstriction (e.g. hyperventilation) Vasodilation (e.g. alcohol, anti-hypertensives, heat)
41 Dysequilibrium (Gait Disorder) Extra-pyramidal ( e.g. Parkinsonism) Spasticity Cerebellar ataxia Sensory ataxia (proprioceptive trouble) Hydrocephalus ( magnetic gait ) Psychogenic (conversion & malingering)
42 Ill-Defined Lightheadedness The core problem is anxiety Dizziness is meant metaphorically Depression may be a component Panic disorders Agorophobia Treatment may include psychotherapy, anxiolytics, antidepressants and cognitive behavioral therapy
43 Drug Treatment of Vertigo Most or all drugs work as centrally acting anticholinergic substances Diphenhydramine mg daily Diphenhydrinate mg daily Meclizine mg daily Promethazine daily Atropine patch Benzodiazepines are weak anti-vertigo drugs, and are mainly useful for associated anxiety Sympathomimetics improve anticholinergic efficacy and reduce soporific side effects Modafanil 200mg daily Methylphenidate 15-60mg daily
44 Dizzy?
45 The Brigham Department of Neurology, M.D., Chairman Brigham & Women s Hospital, Boston, Massachusetts
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