Vertigo
Dr. Hassan Rafaqat
Resident Emergency Medicine | Mayo Hospital Lahore
Introduction- Vertigo
• The perception of spinning or rotation of the
person or their surroundings in the absence of
any actual physical movement.
• It is a symptom, not a diagnosis.
• Disabling/Increased risk of depression.
Dizziness
• The perception of disturbed or impaired
spatial orientation/awareness.
• Vertigo- false sense of motion
• Presyncope- sensation of feeling faint or
lightheaded
• Disequilibrium- sense of unsteadiness when
walking
• Nonspecific dizziness- polysensory disorder
with an anxiety component
Vestibular System
The vestibular system includes:
Peripheral vestibular system: vestibular apparatus, and
vestibular nerve (vestibular component of
vestibulocochlear/acoustic nerve).
Central vestibular system: Vestibular nuclei, and associated
brainstem pathways.
Vestibular System-
Functions
1. Posture and balance (Equilibrium).
2. Awareness of the body in relationship to its
surroundings (Spatial Awareness/Orientation).
Vestibular System-
Functions
Posture is position and alignment of body’s parts (head,
neck, trunk, and limbs) relative to each other and gravity,
whether the body is at rest or in motion.
Balance is the ability to maintain stability and control body’s
movement to prevent falling, whether the body is at rest or
in motion.
Anatomy-Vestibular
Apparatus
Equilibrium Spatial
Awareness/orientatio
n
Semicircular canals Dynamic equilibrium Awareness of
rotational (angular)
motion and dynamic
head position.
Otolithic organs Static equilibrium Awareness of linear
(horizontal and
vertical) motion and
static head position.
Central Vestibular
System- Vestibulospinal
tract
Central Vestibular
System-
Vestibulocerebellar tract
Central Vestibular
System-
Vestibulothalamocortical
tract
Central Vestibular
System- medial
longitudinal fasciculus
Vestibulo-Ocular Reflex
Reflex in response to head rotation by the vestibular
apparatus
Eye movement in the opposite direction of the head
movement
Stabilizes position of the eye in the line of sight during head
movement
Nystagmus
Occurs due to unbalanced vestibular information, often
from unilateral vestibular disease.
Leads to asymmetric stimulation of eye muscles, causing
slow eye movement toward the stimulus.
The cerebral cortex corrects this by rapidly moving the eyes
back to the midline, creating a repetitive cycle.
The direction of nystagmus is defined by the fast (cortical)
phase of eye movement.
The Interaction of Three Systems
1. Visual System
2. Proprioceptive system via Cerebellum
3. Vestibular System
Any disease that causes a mismatch of information from any
two of the three systems may give rise to vertigo
Types of Vertigo
Peripheral vertigo
Central vertigo
Peripheral Vertigo
• Disturbance of Peripheral vestibular
system
• The difference in activity between the two ears
leads to a difference in sensory inputs to the
vestibular nuclei, from which brain detects a
sensation of movement
Benign Paroxysmal
Positional Vertigo (BPPV)
• Caused by Loose calcium carbonate debris
(otoconia) moving in the semicircular canals
dislodged from the utricle.
• Induced/triggered by head movements-
positional vertigo.
• Transient Lasting less than 1 minute.
Dix-Hallpike Test
Dix-Hallpike Test
• Posterior semicircular canal BPPV variant (85% to 95%) –
upbeat and ipsilateral torsional
Vestibular Neuritis/
Labyrinthitis
• Caused by Vestibular nerve/ labyrinth
inflammation
• Constant symptoms lasting more than 24
hours
• Acute vestibular syndrome- must be
differentiated from posterior circulation stroke
• Improves gradually with time and Lasting for
days
Vestibular Neuritis/
Labyrinthitis- Acute
Vestibular Syndrome
(AVS)
• Characterized by sudden onset of vestibular symptoms
lasting more than 24 hours, often due to peripheral or
central causes.
• Acute and constant vertigo
• Nausea and vomiting
• Unsteady gait
• Nystagmus
• Intolerance to head motion (exacerbation of
symptoms)
Head Impulse Test,
Nystagmus, Test of Skew
(HINTS)
• It should be used only in patients with a first
ever episode of constant vertigo.
• Head Impulse Test, or head thrust-test is used
to diagnose vestibular neuritis and
labyrinthitis.
Head Impulse Test
Head Impulse Test,
Nystagmus, Test of Skew
(HINTS)
• Head Impulse Test, or head thrust-test is used
to diagnose vestibular neuritis and
labyrinthitis
• Nystagmus-change in direction on eccentric
gaze
Nystagmus
Peripheral Central
Does not alter in direction Direction changing nystagmus
fatigable Non-fatigable
Suppressed by visual fixation Not Suppressed by visual fixation
Head Impulse Test,
Nystagmus, Test of Skew
(HINTS)
• Head Impulse Test, or head thrust-test is used
to diagnose vestibular neuritis and
labyrinthitis
• Nystagmus-change in direction on eccentric
gaze
• Test of skew (alternate cover test)
Alternate Cover Test
Alternate Cover Test
Alternate Cover Test
Meniere disease
• Caused by Endolymphatic
hydrops/hypertension
• Classic triad of Meniere disease
• Vertigo
• Tinnitus
• Hearing loss
• Recurrent episodes Lasting for 20 minutes to
12 hours
• Long symptoms-free remissions
Unterberger’s Test
Peripheral Vertigo
• Common causes :
• Benign paroxysmal Positional vertigo
• Vestibular neuritis
• Meniere’s disease
Central Vertigo
• Disturbance of Central Vestibular System
• The difference in activity between the two ears
leads to a difference in sensory inputs to the
vestibular nuclei, from which brain detects a
sensation of movement
Central Vertigo
• Common causes :
• Migranous Migraine
• Stroke
• Transient ischemic attack
• Cerebellar tumor
• Acoustic neuroma (Vestibular Schwannoma)
• Multiple sclerosis
Central vertigo
• Nystagmus characteristics
Peripheral Central
Does not alter in direction Direction changing
fatigable Non-fatigable
Suppressed by visual fixation Not Suppressed by visual fixation
Spontaneous Positional
Central Vertigo
Dr. Hassan Rafaqat
Resident Emergency Medicine | Mayo Hospital Lahore
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