7

(Vertigo)
( vertigo)
( ) ( -, -)



( Vertigo)






(dizziness)
Tension type headache


postural hypotension (near syncope) hyperventilation

multiple sensory deficits
proprioception

1. (inner ear)
2. Vestibular nerve
3. Brainstem
4. Cerebellum
5. Temporal lobe
vestibular nerve Peripheral vertigo
Brainstem, cerebellum temporal Lobe Central vertigo

Central Peripheral vertigo

-
-
-
- Visual fixation

-
Cranial
nerve

- Nystagmus

Central vertigo

-
-

-
-

- vertical
rotatory
- nystagmus

- Amplitude

Peripheral vertigo

-
-

-
tinnitus
-
Nystagmus
-

- horizontal
rotatory
- nystagmus

- Amplitude

1. (true vertigo)
( )

2.
Benign paroxysmal positional vertigo
Menieres
disease
( )
3. Benign paroxysmal positional vertigo
1 vestibular
neuronitis central vertigo

4. Benign
paroxysmal positional vertigo Menieres disease
5.
- peripheral vertigo
-

posterior fossa central vertigo basilar
migraine
- tinnitus
peripheral vertigo
-
Central vertigo
- cupulolithaisis
- perilymph fistula
- viral labyrinthitis
vertigo
vertigo

( 1-2 )
-

Vestibular neuronitis
Brainstem / Cerebellar stroke
Multiple sclerosis
Drug intoxication

10

Physiologic (motion sickness)

Menieres disease
Perilymph fistular
Transient Ischemic attack
Migraine
Benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo

Menieres disease
Migraine
Autoimmune inner ear disease
Seizure
Transient Ischemic attack
Otomastoiditis
Vestibular neuritis
Labyrinthine concussion
Spinocerebellar atrophy
Arnold-Chiari malformation
Tumor (Brainstem, Cerebellum)

1. 1-2 (acute vestibular syndrome)

brainstem cerebellum stroke

1.1

. Vestibular
neuronitis
(Vestibular
neuritis,
labyrinthitis)

nystagmus
cochlea

11

1 1-3
vestibular organ vestibular neuronitis

MRI contrast
enhancement membranous labyrinth 8 Herpes
zoster
oticus
vestibular
neuronitis

7
. Brainstem-Cerebellar
stroke
brainstem
occipital lobe
ischemic

Brainstem Cerebellar
infarct
Posterior Inferior Cerebellar artery (PICA) syndrome lateral medullary
infarction (Wallenbergs syndrome) cerebellar infarction
Horners syndrome, cerebellar ataxia
alternating
sensory
loss




cerebellar sign
Anterior Inferior Cerebellar artery (AICA) syndrome lateral pontine
infarction
AICA

peripheral vertigo
tinnitus AICA Labyrinthine artery
8 internal acoustic canal inner ear

Horners syndrome, cerebellar sign
Cerebellar Stroke infarct hemorrhage cerebellum

cerebellar
sign superior cerebellar artery cerebellar

12

hemorrhage
nystagmus cerebellar sign
cerebellar
vermis
cerebellum
finger
to
nose
test
diadokokinensis


trunk ataxia gait ataxia

cerebellar vermis tandem gait
cerebellar vermis


cerebellar stroke

. Brainstem Cerebellar lesion multiple sclerosis
white matter tract Cerebellum
. Drug Intoxication Dilantin
nystagmus

1.2
. Menieres disease tinnitus

Menieres disease endolymph
( endolymphatic
hydrops) endolymph
perilymph
.
Perilymph
fistular

oval windows round window barotrauma

13

. Transient Ischemic Attack vertebrobasilar system

30
1.3
Benign paroxysmal positional vertigo (BPPV)


10-20

BPPV

BPPV
Calcium carbonate semicircular canal posterior semicircular canal
vestibular sensory
receptor
2.

1-2
2.1 Menieres disease tinnitus
1-2


2.2 Benign paroxysmal positional vertigo (BPPV)
Vestibular
neuritis
BPPV
2.3 Autoimmune inner ear disease autoimmunity
Cogan syndrome
(interstitial
keratitis)

Menieres disease
tinnitus


Corticosteriods

14

2.4 Migraine
benign paroxysmal vertigo basilar migraine

brainstem
basilar
migraine


2.5 Seizure temporal lobe vestibular
system (vertiginous epilepsy)
temporal lobe ,
automatism
2.6
Transient
ischemic
attack
vestebrobasilar
system
thrombosis
3
TIA brainstem
3.
3.1
Otomastoiditis


serious
labyrinthitis

3.2
Vestibular
neuritis
vestibular
neuritis


3.3 Labyrinthine concussion




3.4 Spinocerebellar atrophy cerebellum,
spinal cord spasticity
3.5 Arnold-Chiari malformation cerebellar tonsil
foramen magnum downbeat nystagmus

15

3.6
cerebellum



medulloblastoma 8 acoustic neuroma
vestibular portion

1.
Benign paroxysmal positional vertigo
cerebellar stroke

1.1
(dizziness) postural
hypotention
1.2 nystagmus

nystagmus
nystagmus
nystagmus

nystagmus vertical rotatory

horizontal central lesion downbeat nystagmus
nystagmus (quick phase)
cervicomedullary junction
nystagmus central
quick phase quick phase
quick phase peripheral
quick phase
amplitude
nystagmus peripheral
nystagmus central peripheral

16

vertigo nystagmus retina

ophthalmoscope
nystagmus Frezel glass
nystagmus
nystagmus central
nystagmus nystagmus
peripheral nystagmus
nystagmus Benign paroxysmal positional
vertigo
(BPPV)
DixHallpike
test
45


BPPV nystagmus
perilymph
fistula
nystagmus


1.3
tympanic membrane

cerebellar
sign
finger to nose,
heel to knee, diadokokinensis wide base gait
(tandem walk)
cerebellum
7 (facial nerve)

5
(Trigeminal
nerve)
motor system, sensory system,
Horners syndrome
2.
peripheral vertigo
BPPV

audiogram,
electronystagmogram

CT scan MRI

17

antiplatelet anticoagulant
peripheral vertigo
BPPV semicircular canal
utricle (Epleys particle repositioning maneuver)
Menieres disease diuretic
autoimmune inner ear disease Cogans syndrome
corticosteroid

Antihistamine, betahistine calcium antagonist Calcium
antagonist cinnarizine flunarizine

Parkinsonism 40

peripheral vertigo
Metoclopamide, domperidone,
prochlorperazine metoclopamide
oculogyric crisis extrapyramidal system
sedative diazepam
lorazepam




1. ( Wackym PA, Blackwell KE and Nyerges
AM, 1994: Mckee, 1997)

Lesion
Disease
Peripheral Menier's deseases

Treatment
Low salt diet (1-1.5 g Na+/day), Diuretics,

18

Vestibular
disorders Otosyphilis
Viral neurolabyrinthitis
Autoimmune inner ear disease,
Systemic autoimmune disease
causing deafness
Ototoxic
Hormonal disturbance
Central Vertebro-basilar
Vestibular Insufficiency
disorders Migraine
Psychophysiologic dizziness
Familial ataxia syndromes

Betahistine, Aminoglycosides
Penicillin/Amoxicillin/ Doxycycline/
Tetracycline/ Erythromycin & Steroids
Antiviral agents
(Acyclovir for Ramsay-Hunt syndrome)
Immunosuppressants, plasmapheresis

Prevention
Prevention: DM, thyroid
Antiplatelet, Anticoagulant, Neuronal protection
mimodipine, flunarizine
Migraine abortive therapy, migraine prophylaxis
Antidepressants, Tranquilizers
Monoamine oxidase inhibitors
Acetazolamide (Diamox)

2.
( )

Dimenhydrinate

3.
24
4.
1
, (EEG), (MRI),

19

- Antihistamines
- Dimenhydrinate (Dramamine) 25 50 mg 4 6
- Meclizine (Bonamine)

12.5 50 mg 46

- Promethazine (Phenergan )

25 mg 6
25 mg 4 6
- Betahistine
- Betahistine mesilate
6 12 mg 3

(Merislon )
8 16 mg 3

- Betahistine di HCl (Serc )

- Calcium antagonist
- Cinnarizine (Stugeron)
25 mg 3

- Flunarizine (Sibelium )
5 10 mg

- Metoclopramide (Plazil)
- Prochlorperazine (Stemetil)
- Droperidol
(Dehydrobenzperidol)
- Domperidone (Motilium)

- Benzodiazepines
- Diazepam
- Lorazepam

5 10 mg 3
10 mg IM IV
5 10 mg 3
2.5 5 mg 12 . IM IV

Asthma, Glaucoma, Prostate

enlargement

Asthma, Peptic ulcer,

Pheochromocytoma

Parkinsonism

40
GI bleeding,
Pheochromocytoma, Epilepsy,
Extrapyramidal reaction,
Hypotension, Glaucoma,
,

10 20 mg 3

2 10 mg 2 - 4

5 10 mg 4 . IV
0.5 1 mg 3

Glaucoma,

( 1: ) 1

vertigo

20

1. Betahistine mesilate (Merislon)

(vertigo) & (dizziness)
- Meniere disease
- Meniere syndrome
- (Peripheral vertigo)
Efficacy : Betahistine mesilate (Merislon)
Menieres disease

Safety :
Central nervous system :- (case report)
Cardiovascular
:- Ventricular extrasystole (case report)
Dermatologic
:-Rash, pruritis, urticaria
Gastrointestinal
:-Dyspepsia, nausea, peptic ulcer disease
high dose Betahistine placebo
psychomotor performance
Adherance : 6-12 mg 3
Indication :

2. Betahistine dihydrochloride (Serc)

Indication: Meniere disease vertigo
Efficacy : Betahistine dihydrochloride
Quality of life

Safety :
Central nervous system : (case report)
Cardiovascular
: Ventricular extrasystole (case report)
Dermatologic
:Rash, pruritis, urticaria
Gastrointestinal
:Dyspepsia, nausea, peptic ulcer disease
high dose Betahistine placebo
psychomotor performance
Adherance: 8-16 mg 3

21

3. Cinnarizine (Stugeron)
Indication :
Control of vestibular symptom of both peripheral and central origin and of labyrinth disorder
including vertigo, dizziness, tinnitus, nystagmus, nausea and vomiting.
Prophalaxis of motion sickness.
Adjunct therapy for symptoms of peripheral arterial disease.
Safety :



, ,

,

Adherance :- 25 mg 1 3

4. Flunarizine (Sibelium)
Prophylaxis of classic (with aura) or common (without aura) migraine.
Symptomatic treatment of vestibular vertigo (due to a diagnosed functional disorder of the
vestibular system).
Efficacy :- Betahistine 8
Flunarizine
Safety :-Central nervous system :-Anxiety, dizziness, drowsiness, fatigue, insomnia, vertigo
Dermatologic
:-rash
Endocrine & metabolic :-galactorrhea, prolactin levels increased
Gastrointestinal
:-appetite increase, epigastric pain, heartburn, nausea,
vomiting, weight gain, xerostomia
Neuromuscular & skeletal :-weakness,
Indication:

22

Adherance:- 1 capsule 2 - 2

Vertigo
: initial dose: 10 mg at bed time until symptoms are controlled
Chronic vertigo : discontinue if no response within 1 month
Paroxysmal vertigo: discontinue it no response is noted within 2 months

5. Dimenhydrinate (Dramamine)
Indication: Prevention and treatment of symptom of motion sickness, management of vertigo with
disease affecting the vestibular system
Safety : >10%
Central nervous system : Slight to moderate drowsiness
Respiratory
: Thickening of bronchial secretion
1% to 10%
Central Nervous system : Headache, fatigue, nervousness, dizziness
Gastrointestinal
: Appetite increase, weight gain, nausea, diarrhea, abdominal
pain, dry mouth
Neuromuscular & skeletal: Arthralgia
Respiratory
: Pharyngitis
< 1% ( side effect )
Bronchospasm, hepatitis, hypotension, palpitation
Adherance: 25-50 mg every 4-6 hours 400 mg/day
Low-dose cinnarizine dimenhydrinate
(Betahistine)
Low-dose combination cinnarizine Dimenhydrinate

central peripheral
High-dose cinnarizine High dose Dimenhydrinate

23

:
1. Betts T, Harris D, Gadd E. Br J Clin Pharmacol. 1991 Oct;32(4):455-8.
2. Mira E, Guidetti G, Ghilardi L, Fattori B, Malannino N, Maiolino L, et al. Eur Arch Otorhinolaryngol.
2003 Feb;260(2):73-7. Epub 2002 Sep 11.
3. Albera R, Ciuffolotti R, Di Cicco M, De Benedittis G, Grazioli I, Melzi G, et al. Acta Otolaryngol. 2003
Jun;123(5):588-93.
4. Hahn A, Sejna I, Stefflova B, Schwarz M, Baumann W. Clin Drug Investig. 2008;28(2):89-99.
5. Cirek Z, Schwarz M, Baumann W, Novotny M. Clin Drug Investig. 2005;25(6):377-89.
6. Charles FL, Lora LA, Morton PG, Leonard LL. Drug information handbook with international trade
names index.17th edition. Hudson: Lexi-comp; 2008.
7. Watanabe I. et al.: Otolaryngology. Head Neck Surg. 39, 1237, 1967.
8. Okamoto K. et al.: Jpn. J. Nat. Med. Serv., 22, 650, 1968.
9. cueid.org [homepage on the Internet]. : (Vertigo) [Accessed:
2010 May 7]. Available from:
URL:http://www.cueid.org/component/option,com_docman/task,cat_view/gid,92/Itemid,42/
10. . . : ; 2544. 367368.