Vertigo
Vertigo
Vertigo is an illusion of movement, a sense of rotation or of tilt, causing a feeling of imbalance or dysequilibrium. It is a subtype of "dizziness", to be distinguished from the light-headedness of general medical conditions (vasovagal attacks, presyncope, cardiac dysrhythmias). Vertigo is often triggered by head movement and there may be associated autonomic features (sweating, pallor, nausea, vomiting). Vertigo may be horizontal, vertical or rotatory.
Pathophysiologically, vertigo reflects an asymmetry of signaling anywhere in the central or peripheral vestibular pathways. Clinically it may be possible to draw a distinction between central and peripheral lesions: in the latter there may be concurrent hearing loss and tinnitus (reflecting vestibulocochlear (VIII) nerve involvement). Facial weakness (VII) and ipsilateral ataxia suggest a cerebellopontine angle lesion; diplopia, bulbar dysfunction and long tract signs are suggestive of a central pathology. Peripheral vertigo tends to compensate rapidly and completely with disappearance of nystagmus after a few days, whereas central lesions compensate slowly and nystagmus persists.
The clinical pattern of vertigo may gives clues as to underlying diagnosis:
| Vertigo | Peripheral | Central |
|---|---|---|
| Acute Prolonged, spontaneous |
Labyrinthitis Otomastoiditis Vestibular neur(on)itis Labyrinthine concussion Isolated labyrinthine infarct Vestibular nerve section Drug-induced |
Brainstem/ cerebellum hemorrhage/ infarct/ demyelination |
| Recurrent, episodic |
Ménière’s disease (endolymphatic hydrops) Autoimmune inner ear disease (isolated, systemic) Perilymph fistula Migraine (rare) Epilepsy (rare) |
Vertebrobasilar ischemia (with associated features) |
| Positional | Benign paroxysmal positional vertigo (BPPV) |
4th ventricle lesions: multiple sclerosis Chiari malformation Brainstem/ cerebellar tumors Spinocerebellar atrophy |
| Chronic | Vestibular decompensation/failure |
Neurological disorder Psychogenic |
All patients with vertigo should have a Hallpike maneuver performed during the examination.
Specific treatments are available for certain of these conditions. A brief course of a vestibular sedative (cinnarizine, Serc) is appropriate in the acute phase, but exercises to "rehabilitate" the semicircular canals should be begun as soon as possible in peripheral causes. In BPPV, most patients respond to the Epley maneuver to reposition the otoconia which are thought to cause the condition (canalolithiasis). Brandt-Daroff exercises are an alternative. Cawthorne-Cooksey exercises are helpful in vestibular decompensation or failure.
References
Baloh RW. Vertigo. Lancet 1998; 352: 1841-1846
Brandt T. Vertigo: its multisensory syndromes (2nd edition). London: Springer, 1999
Hain TC, Uddin MK. Approach to the patient with dizziness and vertigo. In: Biller J (ed.). Practical neurology (2nd edition). Philadelphia: Lippincott Williams & Wilkins, 2002: 189-205
Luxon LM. Vertigo: new approaches to diagnosis and management.
British Journal of Hospital Medicine 1996; 56: 519-520, 537-541
Cross References
Ataxia; Caloric testing; Facial paresis; Hallpike maneuver, Hallpike test; Hennebert’s sign; Illusion; Nystagmus; Vestibulo-ocular reflexes
