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LEARNING
SHARING
TEACHING
WHAT IS VERTIGO?
A SENSATION OF MOVEMENT
CHARACTERISED BY FEELING
OF ROTATION OR SPINNING
VERTIGO PREVALENCE
Inner ear
Muscle and joint
(vestibular system)
sensory receptors
Central Nervous system
Balance
Utricle Otolith
Semicircular Saccule organs
canals
Vestibular nerve
Cochlea
Ampullae
Dizziness
Drachman DA, Hart CW. Neurology 1972;22:3234. Sloane PD et al. Ann Intern Med 2001;134:82332.
Vertigo can be of central or
peripheral origin
Central
Involving structures in
the central nervous
system
(e.g., cerebrum,
cerebellum, brainstem)
Peripheral
Involving structures not
part of the central
nervous system, most
frequently the inner ear
VERTIGO
PERIPHERAL vs CENTRAL
Symptom Likely aetiology
Peripheral Central
Vertigo episodes Mild/modete Chronic and
unremitting
Symptom onset Sudden Gradual
Imbalance Mild/modete Severe
Nausea, vomiting Severe Varying
Auditory symptoms Common Rare
Neurological symptoms Rare Common
Changes in mental status/ Infrequent Sometimes
consciousness
Compensation/resolution Rapid Slow
Baloh RW. Otolaryngol Head Neck Surg 1998;119:559. Puri V, Jones E. J Ky Med Assoc 2001;99:31621.
PRACTICAL POINT
PERIPHERAL VERTIGO:
SUDDEN ONSET
WITH NAUSEA AND VOMITING
NO NEUROLOGICAL SYMPTOM
NO CHANGE IN COUNCIOUSNESS
CENTRAL VERTIGO:
GRADUAL ONSET
PERSISTING DURATION
SEVERE IMBALANCE
NEUROLOGICAL SYMPTOM (+)
Vertigo of Peripheral origin: causes
Condition Details
Benign paroxysmal Brief, position-provoked vertigo episodes caused by
positional vertigo abnormal presence of particles in semicircular canal
(BPPV)
Menieres disease An excess of endolymph, causing distension of
endolymphatic system
Decreasing frequency
Baloh RW. Lancet 1998;352:18416. Mukherjee A et al. JAPI 2003;51:1095-101. Parnes LS et al. CMAJ
2003;169:681 93. Puri V, Jones E. J Ky Med Assoc 2001;99:31621. Salvinelli F et al. Clin Ter 2003;154:3418.
Vertigo of Central origin: causes
Condition Details
Migraine Vertigo may precede migraines or occur concurrently
Baloh RW. Lancet 1998;352:18416. Mukherjee A et al. JAPI 2003;51:1095-101. Salvinelli F et al. Clin Ter 2003;154:
3418. Solomon D. Otolaryngol Clin North Am 2000;33:579601. Strupp M, Arbusow V, Curr Opin Neurol 2001;14:1120.
IMPACT OF VERTIGO EPISODE / CRISIS
CONTINUOUS BURDEN
Baloh RW. Otolaryngol Head Neck Surg 1998;119:559. VOR, vestibular-ocular reflex. MRI, Magnetic Resonance Imaging.
2. Recurrent episodes sensitive to head position
Investigate history: Prior ear infection? Head trauma?
Perform MRI
Baloh RW. Otolaryngol Head Neck Surg 1998;119:559. MRI, Magnetic Resonance Imaging.
3. Recurrent episodes insensitive to head position
Investigate history: Age? Attack duration? Hearing loss?
Neurological symptoms? Migraine? Autoimmune illness?
Blood screen
Baloh RW. Otolaryngol Head Neck Surg 1998;119:559. MRI, Magnetic Resonance Imaging. ENG, Electronystagmogram.
CURRENT MANAGEMENT OPTIONS
TREATMENT MODALITIES
1.Treat the underlying cause
Pharmacotherapy
Particle repositioning procedure (in BPPV)
Surgery
2. Symptomatic
Pharmacotherapy
3. Rehabilitative
Promote long-lasting neural reorganisation
Vestibular rehabilitation exercises
CENTRAL CAUSE
Migraine Beta-blockers, calcium channel blockers, tricyclic amines
Goebel JA. Otolaryngol Clin North Am 2000;33:48393. Salvinelli F et al. Clin Ter 2003;154:3418.
2. SYMPTOMATIC THERAPY
ANTIVERTIGO
I. Vestibular Suppressant
1. Ca antagonist : Flunarizin
2. Vasodilator : Betahistine
3. Tranquilizer : diazepam, haloperidol, sulpiride
4. Antihistamin : Difenhidramine, meclizine.
5. CNS stimulant: ephedrin, amphetamin
II. Antiemetic
1. Anticholinergic : atropine, scopolamine
2. Phenotiazine : Prochlorperazine, metoclopramide.
NOOTROPIL
Balance requires information of similar
intensity from both vestibular systems
Head movement
Central nuclei
10 10
10 10
Central nuclei
5 10
5 10
1 2
5 10
80 76
% patients with symptom
72
68
64 64
60 52
40 32 32
28 28 28
24
20 20
20
0 0
0
Nystagmus Index Imbalance Star Nystagmus Index Imbalance Star
deviation gait deviation gait
-5
-10
-15
-20
p<0.01 p<0.01 p<0.05
Adapted from Rosenhall U et al. Clin Drug Invest 1996;11:25160. Day 84 is 4 weeks after cessation of treatment.
Nootropil is well tolerated in
clinical trials
Incidence of adverse events (%) in pooled analysis (completed in 1997)
of 91 placebo-controlled trials
1. PATIENT EDUCATION
2. EXPLAIN THE RISK
3. KEEP IN TOUCH
4. ENCOURAGEMENT
5. PAY ATTENTION
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