Approach to a Dizzy Patient

Approach to a Patient with Dizziness and Ataxia:

Dr Rahul Chakor Associate Professor of Neurology Approach to a Patient with Dizziness and Ataxia

Objectives:

Objectives Rational approach to a dizzy patient To differentiate between dizziness, vertigo, ataxia To differentiate between vestibulocerebellar and peripheral causes of vertigo Localize vestibulocerebellar lesions causing central vertigo

Dizziness:

Dizziness Nonspecific term Describe the sensation of dizziness What do you mean by dizziness Is it true rotatory feeling like spinning of a top Is it slow or fast The side of rotation of self or surrounding Pushing, pulling or being thrown sensation

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True Vertigo Not a true vertigo Imbalance – Ataxia (cerebellar or sensory, spastic) May be a seizure (unconsciousness, jerks, staring, automatism etc) Syncope Heaviness in the head Eye strain Blurred vision, diplopia True Vertigo Not a true vertigo Imbalance – Ataxia (cerebellar or sensory, spastic) May be a seizure (unconsciousness, jerks, staring, automatism etc) Syncope Heaviness in the head Eye strain Blurred vision, diplopia

True vertigo:

True vertigo Common symptom 30% lifetime prevalence Peripheral frequent than central Disabling and Serious Important to differentiate Common symptom 30% lifetime prevalence Peripheral frequent than central Disabling and Serious Important to differentiate

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Approach to true vertigo

Approach:

Approach History Neurological Examination Extended Vestibular examination Investigations 90% 10%

History:

History Four Questions Is it true Vertigo – Form How long does the vertigo last - Duration, I s It An Attack Are there any triggers - Posture, Head Turning, Heights Associated symptoms - Diplopia, Headache, Limb Ataxia, Dysarthria, Dysphagia, Facial Weakness, Limb Weakness, Drowsiness, Unconsciousness

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Peripheral Central Site of Origin

Frequency of different vertigo syndromes:

Frequency of different vertigo syndromes

Central Vertigo:

Central Vertigo Origin Brainstem Cerebellum Vestibulocerebellar Connections Cortex Etiology Cerebrovascular diseases Basilar Migraine Multiple Sclerosis Rare Epilepsy CPA Tumors

Vertigo:

Central Peripheral Do not always complaint of true vertigo Imbalance Incoordination Disequilibrium Cannot maintain posture, stand Cannot walk Falling, Pulling, Pushing, Being thrown True vertigo Vertigo

Associated Symptoms:

Central Vertigo Peripheral Vertigo Gradual Onset Less intense No postural aggravation Diplopia Dysarthria , Dysphagia, Hoarseness Facial weakness, Hearing Loss Hemiparesis Ataxia Headache, Impaired Consciousness Acute Onset Severe vertigo Postural aggravation & precipitation Nausea, Vomiting Associated Symptoms

Central Nystagmus:

Central Peripheral Pure - horizontal, vertical or torsional No fixation - suppression Less intense Multidirectional - towards the gaze Upbeat- Pons Downbeat - Medulla Mixed - Horizontal + rotational/ torsional Fixation Suppression Intense - ↑ Amplitude in direction of fast phase Fixed direction - Opposite the affected ear Central Nystagmus

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BPPV 3-40 sec Yes Yes Severe Variable Central Positional Vertigo None None None Mild Good Feature Latency Fatigability Habituation Intensity Reproducibility Central Positional Vertigo

Central and Peripheral Vertigo:

Central and Peripheral Vertigo AICA Infarction - Labyrinth, Pons, Cerebellum Migraine Vertebrobasilar Ischemia

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Localization and etiology of central vertigo

Wallenberg Syndrome/Lateral Medullary Infarction:

Vertebral artery, PICA Ocular Signs Medial Vestibular Nucleus Posterior (vertical) Semicircular Canal Pathway Ipsiversive lateropulsion Skew deviation Excyclotorsion Vertigo Cerebellar Vermis- Uvula, Nodulus Wallenberg Syndrome/Lateral Medullary Infarction Diplopia, Dysphagia, Hoarseness, Hiccups, Nausea, Vomiting, Horner's Syndrome, Trigeminal facial loss, Spinothalamic loss in Contralateral limbs Vertigo Cerebellar Vermis- Uvula, Nodulus

Medial PICA syndrome:

mPICA not involving medulla Partial Wallenberg Syndrome Pure vertigo Medial & caudal cerebellar infarct - nodule, vestibulocerebellum Misdiagnosed as labyrinthitis Central Vertigo mimicking as Peripheral Vertigo Vertigo Headache, Gait Ataxia, Appendicular Ataxia, horizontal nystagmus Lateropulsion Medial PICA syndrome

Lateral Inferior Pontine Syndrome AICA Infarcts:

Classic Partial Vertigo Tinnitus, deafness, facial palsy Dysphagia, Horners syndrome Trigeminal sensory loss, contralateral limb spinothalamic loss, ataxia Isolated Vertigo mimicking labyrinthitis Labyrinth, eight nerve, vestibular nucleus Vestibulocerebellum –Flocullus Central Vertigo mimicking as Peripheral Vertigo Lateral Inferior Pontine Syndrome AICA Infarcts

Other Ischemic Causes:

Other Ischemic Causes Functional Compression of Vertebral Artery Cervical spondylosis , osteophytes Risk factors for atherosclerosis Neurovascular Compression of Eighth Nerve Vestibular Paroxysmia Lacunar Infarct Root Entry zone, Vestibular nuclei

Migraine:

Migraine Vertigo with or without Headache Basilar Migraine Benign recurrent vertigo (BRV) is Migraine ? - Internal auditory artery spasm Association with Menieres disease - Prevalence is high Family history of motion sickness and migraine Response to beta blockers and flunarizine

Epilepsy:

Epilepsy Vestibular Cortex - A network Superior temporal gyrus, the long insular and transverse temporal gyrus, and the medial temporal gyrus Vertigo - Aura → secondary generalization → LOC Visuospatial illusion, diisociation Isolated Vertigo as epileptic seizure is rare Multiple Seizure types

Channelopathies:

Channelopathies Episodic Ataxia type 2 - Mutation in CACNA1A on 19 q Allelic with Familial Hemiplegic Migraine (FHM), SCA6 Increased incidence of Epilepsy Episodes of Ataxia lasting hours to days, vertigo, nausea and vomiting In between - Nystagmus, slowly progressive ataxia Cerebellar atrophy of anterior vermis Response to Acetazolamide

Multiple Sclerosis:

Multiple Sclerosis Demyelinating Plaque - REZ of VIII nerve mimicking vestibular neuronitis Central nystagmus - Gaze evoked nystagmus, down beat nystagmus, upbeat Internuclear Ophthalmoplegia 2 lesions disseminated in time and space Vertigo at presentation - 5 % of patients

Infratentorial Neoplasm :

Infratentorial Neoplasm

Summary:

Summary History is the key to diagnose Central Vertigo Neurological Examination is the key for localization Central Vertigo may not be “True Vertigo” Posterior Circulation diseases, Multiple Sclerosis, Posterior fossa Neoplasms are usual causes of Central Vertigo

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Thank You