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Notification: The patient experiences vertigo and disorientation. Step to approach vertigo:

1. Differentiate true vertigo:

  • Vertigo arises from abnormalities in the vestibular, cerebellar, or brainstem areas, causing symptoms such as:

  • A sense of spinning or the illusion of movement.

  • Oscillopsia (jumpy vision) due to nystagmus.

  • A sense of imbalance, causing difficulty standing or walking unsteadily.

  • Symptoms from the autonomic nervous system like nausea/vomiting, palpitation, hypertension, and sweating.

  • It's important to distinguish these from other symptoms:

  • Dizziness: A feeling of lightheadedness that can stem from systemic or neurogenic conditions.

  • Headache: Can be localized more precisely than vertigo.

  • Fainting or Lightheadedness: Suggests syncope.

  • Dysequilibrium: Loss of balance from non-vestibular causes like proprioception or vision issues.

2. Differentiate central from peripheral vertigo:

  • The balance control system starts from the vestibular organ in the inner ears, through the vestibular nerve (CN VIII), to the brainstem, cerebellum, and temporal lobe of the cerebrum.

  • Central and peripheral vertigo are differentiated at CN VIII (above CN VIII is central vertigo).

Signs and Symptoms:

  • Hearing loss, tinnitus: Absent in central vertigo, often present in peripheral vertigo.

  • Nausea/Vomiting: Usually absent in central vertigo, usually present in peripheral.

  • Vertigo: Mild in central, severe and often rotational in peripheral.

  • Falling: Toward the side of the lesion in central, to the side opposite nystagmus in peripheral.

  • Latency and duration: No latency and persistence >60 sec in central, latency after head motion and persistence <60 sec in peripheral.

  • Caloric test: Normal in central, abnormal on the side of the lesion in peripheral.

  • Neurological deficit: Often present in central, absent in peripheral.

  • Nystagmus: Vertical or rotatory with no specific pattern in central, horizontal in peripheral, with the fast phase towards the normal side, increasing when looking towards the normal side and decreasing when looking towards the affected side.

  • Visual with eye fixation: No change in central, inhibits nystagmus and vertigo in peripheral.

3.Etiology differentiation:

  • Types and Main Differential Diagnosis:

  • Spontaneous acute vestibular syndrome: Posterior circulation stroke (brainstem/cerebellar stroke), Vestibular neuritis.

  • Triggered episodic vestibular syndrome: BPPV, Orthostatic hypotension.

  • Spontaneous episodic vestibular syndrome: Meniere’s disease, Vestibular migraine, Reflex syncope, Vertebrobasilar TIA.

  • Chronic vestibular syndrome: Degenerative brain disorder, Bilateral vestibulopathy.

  • Differential diagnosis should also consider dizziness, tension headache, anxiety, and drug-induced conditions.

Diagnostic Approach to Vertigo

  • Initial Assessment: Differentiate between peripheral and central vertigo based on the history and physical examination. Peripheral vertigo is often characterized by episodic, severe symptoms with auditory findings, whereas central vertigo presents with milder, continuous symptoms without hearing loss but may include other neurological deficits.

  • Physical Examination:

  • Vital Signs: Check for orthostatic hypotension.

  • Neurological Exam: Look for neurological deficits to consider central causes like stroke. AICA and PICA strokes can present with vertigo and specific syndromes (e.g., lateral pontine syndrome with AICA stroke, lateral medulla syndrome with PICA stroke).

  • Head Impulse/Thrust Test: Evaluate the vestibulo-ocular reflex. Normal response indicates a functional reflex, while an abnormal response (catch-up saccades) suggests a peripheral lesion.

Symptomatic Treatment in Peripheral Vertigo

  • Dimenhydrinate: For symptomatic treatment, available in IV (50 mg stat then every 4 hours) and oral forms (50 mg 1 tab tid pc or 1-2 tabs prn every 4-6 hours).

  • Betahistine Mesylate (Merislon): Specifically for Meniere’s disease, dosed at 12 mg orally tid.

  • Cinnarizine HCl: For symptomatic treatment, 25 mg 1-2 capsules orally tid pc.

  • Flunarizine: For symptomatic treatment, 5 mg 1-2 tablets orally at bedtime.

  • Metoclopramide (Plasil): Antiemetic, 10 mg IV stat then every 6 hours.

  • BPPV Treatment: Epley’s Maneuver is recommended, noting that medication is not helpful in managing BPPV.

Clinical Insights

  • BPPV (Benign Paroxysmal Positional Vertigo): Managed with Epley’s Maneuver, focusing on repositioning canaliths in the semicircular canal back to the utricle.

  • Central Vertigo: Consider stroke among the differential diagnoses, especially with vascular risk factors or isolated vertigo with neurological signs.

This detailed overview integrates critical aspects of vertigo management from initial evaluation to specific therapeutic interventions, emphasizing both the differential diagnosis process and the tailored treatment strategies for peripheral and central vertigo. These insights are vital for medical students and professionals in diagnosing and managing vertigo, highlighting the importance of a systematic approach and patient-centered care in clinical practice.

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