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Nurdjaman Nurimaba
Neurological Department, Medical Faculty Padjadjaran University Bandung - Indonesia


Vertigo : frequently complaints.

- Acute vertigo - Provoked vertigo - Poor balance

Acute Spontaneus Vertigo due to acute spontaneus unilateral depression of vestibular function.
Provoked Vertigo due to unilateral excitation of vestibular function. Poor Balance due to chronically inadequate peripheral or central vestibular or cerebellar function.

A. Acute Spontaneus Vertigo

Sudden unilateral, impairment of vestibular function. One side suddenly stop working. Loss of peripheral input (e.g attacck of Menieres during Labyrinthectomy ). Agravated by head motion and often by lying down. Relieved by sitting up right, keeping the head still or lying with intact side lowermost.

Vertigo continous with eye clossed. Ussually too distressed to note of self rotation. Nystagmus is present. Phenomenon as double vision. Standing and walking are repaired. Might falls to affected siden. Automic disturbance.

Consider Acute SpontaneusVertigo


Those with recurring attack that last minutes to hours. Those who have had a single severe attack that lasted more than 1 day.



Those who present during a vertigo attack.

B. Recurring attacks of acute spontaneus vertigo lasting minutes to hours.

Sudden, temporary, largely reversible impairment of resting neural activity of one labyrinth, with subsequent recovery to normal. Last minutes to hours. Common vertigo problem seen in office practice. Well at the time of consultation. If clinical examination and laboratory test not helpful, diagnosis hinge on the history

Fact such as the following may be critical :


2. 3.

The temporale profile vertigo, lasting minutes with vertebrobasilar ischaemia and multiple sclerosis or hours with Menieres disease. Simultaneous neurological symptom. The background history migrain headache, vascular headache, head injury.
Recurrent vertigo lasting at least 2 to 3 hours, simplest way to make diagnosis : vestibular evaluation during a vertigo attack

Common causes of recurrent spontaneous vertigo :

a. b.



Mennieres dissease and its variant. Migraine. Vertebrobasilar transient ischaemia brainstem or labyrinthine. Perilymph fistula. Autoimmune inner ear disease. Multiple sclerosis.

C. Single attack of acute spontaneous vertigo lasting more than 24 hours

Severe attack of vertigo. Only sometime. Already well. Symptom last several days. Has been sudden permanent impairment of the function of 1 labyrinth or central connections. Improvement by compensation.

Common causes of a single attack of vertigo lasting more than 24 hours.

b. c.

e. f.


Vestibular neuritis. Vertebrobasilar infarction. Menieres disease. Cerebelar or brainstem hemorrhage. Bacterial labyrinthitis. Autoimmune neurolabyrinthitis. Multiple sclerosis.

After 4 to 6 weeks might patient be asymptomatic, might no residual abnormalities detectible clinically.

Ongoing attack of acute spontaneous vertigo :

First task then is to determine vertigo central or peripheral. Truly the patients first attack. Other presenting symptom. Familiarity

Provoked Vertigo

Due to sudden inappropriate excitation. Stimulated cupula of a semicircular canal in patient with benign positional vertigo or by transmitted pressure in patients with a perilymp fistula.

A. Position Provoked Vertigo

An illusion of rotation (vertigo) brought on by a change in head position with respect to gravity. Occur in lesions of the peripheral labyrinth and central vestibular pathways.

Peripheral labyrinthine lesions :

Inappropiate excitation of crista of one semicircular canal. Brainstem and cerebellar lesions can cause a more persistent positional vertigo accompanied by different types of nystagmus.

Common causes :

Fossa posterior Chiari malformations. Cerebellar degeneration. Multiple sclerosis

B. Pressure provoked vertigo :

- Provoked by valsava-like maneuver. - less common than position provoked vertigo. - typical of an abnormal communication between the middle and inner ear. - fistula can occur after head injury, ear surgery or erosion of lateral canal by cholesteatoma. - Nystagmus provoked by pressure in the external auditory canal.

Hyperventilation provoked vertigo

In patient with several labyrinthine and vestibular nerve disorders. Infrequenly. Reported in association with acoustic neuroma and cholesteotoma, sequelle of vestibular neuritis. Mechanism is uncertain. Probably result from hyperventilation induced changes in turn increase the excitability or partially damaged vestibular nerve.

Poor balance

Two of most common causes are : - cerebellar - vestibullar Chronic vestibular insufficiency : - ototoxic drug. - congenital & hereditary disorders. - autoimmune disease. - bilateral Menieres disease. - temporal bone infection. - bilateral acoustic neuroma. - idiophatic bilateral isolated. - severe unilateral vestibular loss of any cause.

Symptom of CVI

Head movement oscilopsia.

Imbalance particularly if visual and proprioceptive input are reduced or disrupted. Spatial disorintation in circumtances of reduced visual or preprioceptive.

Cerebellar disease produce disturbances : - vestibulo ocular

- vestibulo spinal motor control. Including : Position provoked vertigo. Nystagmus. Positive Romberg test. Horizontal and vertical smooth pursuit. Tremor. Dysarthria.

Common cause of cerebellar dysfunction.

Hereditary or acquired cerebellar degenerations. Cerebellar tumor. Chiari malformation. Multiple sclerosis. Cerebellar infarction. Certain drug.

Thanks for your attention

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