Central neurogenic vertigo
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Transcript of Central neurogenic vertigo
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