Vertigo

Abdul GofirRS Sardjito/FK-UGM

Anatomic and Physiologic Anatomic and Physiologic Components of BalanceComponents of Balance

Vestibular – labyrinth, vestibular Vestibular – labyrinth, vestibular nucleinuclei

Visual – CN III, IV, VI Visual – CN III, IV, VI Proprioceptive – upper cervical Proprioceptive – upper cervical

ms and jointsms and joints

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Timothy 2006

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PatofisiologiPatofisiologi

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NORMAL PROCESSINGNORMAL PROCESSING

Vestibular systemVisus

Propiocepsis

Sensory information

= coordinated

CENTRA

Oculomotor centra

Stabilization of visual field

Muscles of the body

Static and kinetic equilibrium

= known pattern

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ABNORMAL PROCESSINGABNORMAL PROCESSING

Vestibular systemVisus

Propiocepsis

Sensory information

=abnormal=Excesive=Discordant information

stimuli

CENTRA

= unknown patern

Oculomotor centra: NISTAGMUS

Muscles : DEVIATION

ALARMWARNING

CORTEX BECOMES CONSCIOUSAFFECTIVE COMPONENT VERTIGO

NEUROVEG. CENTRA

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PATOFISIOLOGI VERTIGOPATOFISIOLOGI VERTIGO

Reseptor Pengelola data Efektor

• Mata• Vestibuler• Propioseptik

Saraf Pusat • Otot skelet• Mata• Leher• Badan• Anggota gerak

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VERTIGO TEORY

1. Sensoris Conflict • Rangsangan di atas ambang fisiologis• Banjir informasi

2. Neural mismatch• Comparator - memori

3. Ketidakseimbangan saraf otonomik• Akibat rangsangan gerakan parasimpatis

4. Neurohumoral• Akibat rangsangan gerakan CRF (dr.hipotalamus)

ss.sym – strs.hrmn

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Receptor Central Nervous System Sign & Simptom

Cerebral cortex

Vestibular Cerebellum

Vestibular Nuclei

CTZ

Vomiting centre

Autonomiccentres

Hypothalamus

Pituitary

Retina

VestibularApparatus

SomatosensoryReceptors

Motionstimuli

NAUSEADizzinessSomnolenceHeadacheDepressionPerformance-decrement

Increased Secretion ofADH, ACTH, GH, PRL

SWEATINGPALLORDecreased Gastric motility,Cardiovasculer &Inspiratory changes

VOMITINGKONFLIK SENSORISKONFLIK SENSORISBack

Neural MismatchNeural Mismatch

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Sensory RearrangementSensory Rearrangement

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NEUROHORMONALNEUROHORMONAL

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Head Acceleration Head angular Velocity Endolymph Displacement

Cupular AngleCilia Bending

Receptor Cell Potential

Synaptic Action

Generator Potential

Primay AfferentAction Potentials

CNS

PostureVORPerception

Ket: CNS: Central Nervous SystemVOR: Vestibulo Ocular Reflex

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STRESS Behavioral ChangesCIRCADIAN RYTHMS

5-H-T

Ach

GABA

CRF

PITUITARY

ACTH

ADR CORTEX

STEROIDS

(+)

(+)

Multiple Physiological Responses/Pathology

(-)

(-)(+)

LO

CSS

ADR.MED

LYMPHOCYTES

ACTH

HIPPOCAMPUSCORTEX

ANTIGENS

IL(-)

IMUNOLOGICALRESPONSESIMUNOSUPRESSION

(-)

?

SSP

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KETERANGAN:KETERANGAN: 5 HT5 HT : Serotonin: Serotonin AchAch : Acetyl Cholin: Acetyl Cholin GABAGABA : Gama Amino Butyric Acid: Gama Amino Butyric Acid CSSCSS : Central Sympathic System: Central Sympathic System ADR.MEDADR.MED : Adrenal Medula: Adrenal Medula (+)(+) : Exitatory: Exitatory (-)(-) : Inhibitory: Inhibitory CRFCRF : Corticotropin Releasing Factor: Corticotropin Releasing Factor ACTHACTH : Adreno Corticotropic Hormon: Adreno Corticotropic Hormon ADR. Cortex ADR. Cortex : Adrenal Cortex: Adrenal Cortex

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Cervicogenic VertigoCervicogenic Vertigo Hx of neck trauma, muscle spasmHx of neck trauma, muscle spasm Limited cervical ROMLimited cervical ROM Positive chair rotation test (Fitz-Ritson)Positive chair rotation test (Fitz-Ritson) Patients may complain of dysequilibrium Patients may complain of dysequilibrium

(tilt) more than rotational vertigo(tilt) more than rotational vertigo Overstimulation of upper cervical Overstimulation of upper cervical

proprioceptorsproprioceptors May overlap BPPV or Meniere’s diseaseMay overlap BPPV or Meniere’s disease

Vertigo PeriferVertigo Perifer

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Benign Paroxysmal Benign Paroxysmal Positional Vertigo (BPPV)Positional Vertigo (BPPV)

Inner ear problem that results in short Inner ear problem that results in short lasting, but severe, room-spinning vertigo. lasting, but severe, room-spinning vertigo.

BenignBenign: not a very serious or progressive : not a very serious or progressive conditioncondition

ParoxysmalParoxysmal: sudden and unpredictable in : sudden and unpredictable in onset onset

PositionalPositional: comes with a change in head : comes with a change in head positionposition

VertigoVertigo: causing a sense of dizziness. : causing a sense of dizziness.

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Canalolithiasis TheoryCanalolithiasis Theory The most widely accepted theory of the The most widely accepted theory of the

pathophysiology of BPV pathophysiology of BPV Otoliths (calcium carbonate particles) are normally Otoliths (calcium carbonate particles) are normally

attached to a membrane inside the utricle and sacculeattached to a membrane inside the utricle and saccule The utricle is connected to the semicircular ducts The utricle is connected to the semicircular ducts These otoliths may become displaced from the utricle These otoliths may become displaced from the utricle

to enter the posterior semicircular duct since this is to enter the posterior semicircular duct since this is the most dependent of the 3 ducts the most dependent of the 3 ducts

Changing head position relative to gravity causes the Changing head position relative to gravity causes the free otoliths to gravitate longitudinally through the free otoliths to gravitate longitudinally through the canal. canal.

The concurrent flow of endolymph stimulates the hair The concurrent flow of endolymph stimulates the hair cells of the affected semicircular canal, causing cells of the affected semicircular canal, causing vertigo.vertigo.

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CausesCauses

IdiopathicIdiopathic Infection (viral neuronitis)Infection (viral neuronitis) Head traumaHead trauma Degeneration of the peripheral end organDegeneration of the peripheral end organ Surgical damage to the labyrinthSurgical damage to the labyrinth

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SymptomsSymptoms Starts suddenly Starts suddenly first noticed in bed, when waking from first noticed in bed, when waking from

sleep. sleep. Any turn of the head bring on dizziness. Any turn of the head bring on dizziness. Patients often describe the occurrence of Patients often describe the occurrence of

vertigo with vertigo with tilting of the head, tilting of the head, looking up or down (top-shelf vertigo) looking up or down (top-shelf vertigo) rolling over in bed. rolling over in bed.

nausea and vomiting. nausea and vomiting. There is no new hearing loss or There is no new hearing loss or tinnitus.tinnitus.

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DiagnosisDiagnosis

Lab Studies: Lab Studies: No pathognomonic laboratory test for No pathognomonic laboratory test for

BPV exists. Laboratory tests may be BPV exists. Laboratory tests may be ordered to rule out other pathology.ordered to rule out other pathology.

Imaging Studies: Imaging Studies: Head CT scan or MRI.Head CT scan or MRI.

Procedures: Procedures: The Dix-Hallpike test, along with the The Dix-Hallpike test, along with the

patient's history, aids in the diagnosis of patient's history, aids in the diagnosis of BPV. BPV.

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The Dix-Hallpike testThe Dix-Hallpike test

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TreatmentTreatmentMedicationsMedicationsThe Canalith The Canalith Repositioning Repositioning Procedure (CRP)Procedure (CRP)

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Canalith Repositioning Canalith Repositioning Procedure Procedure

( CRP )( CRP ) The treatment of choice for BPPV. The treatment of choice for BPPV. Also known as the Epley maneuver, Also known as the Epley maneuver, The patient is positioned in a series of steps so as to slowly The patient is positioned in a series of steps so as to slowly

move the otoconia particles from the posterior semicircular move the otoconia particles from the posterior semicircular canal back into the utricle. canal back into the utricle.

Takes approximately 5 minutes. Takes approximately 5 minutes. The patient is instructed to wear a neck brace for 24 hours The patient is instructed to wear a neck brace for 24 hours

and to not bend down or lay flat for 24 hours after the and to not bend down or lay flat for 24 hours after the procedure. procedure.

One week after the CRP, the Dix-Hallpike test is repeated. One week after the CRP, the Dix-Hallpike test is repeated. If the patient does experience vertigo and nystagmus, then If the patient does experience vertigo and nystagmus, then

the CRP is repeated with a vibrator placed on the skull in the CRP is repeated with a vibrator placed on the skull in order to better dislodge the otoconia. order to better dislodge the otoconia.

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The Epley ManeuverThe Epley Maneuver

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Clinical TrialClinical TrialRuckenstein (2001) Ruckenstein (2001) Therapeutic efficacy of the Epley Therapeutic efficacy of the Epley

canalith repositioning maneuver.canalith repositioning maneuver. Laryngoscope Laryngoscope

Eighty-six patients Eighty-six patients 74% of cases that were treated with one or two 74% of cases that were treated with one or two

canalith repositioning maneuvers had a resolution canalith repositioning maneuvers had a resolution of vertigo as a direct result of the maneuver. of vertigo as a direct result of the maneuver.

A resolution attributable to the first intervention A resolution attributable to the first intervention was obtained in 70% of cases within 48 hours of the was obtained in 70% of cases within 48 hours of the maneuver. maneuver.

An additional 14% of cases that were treated had a An additional 14% of cases that were treated had a resolution of vertigo.resolution of vertigo.

Only 4% of cases (three patients) manifested BPV Only 4% of cases (three patients) manifested BPV that persisted after four treatments. that persisted after four treatments.

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Differential DiagnosisDifferential Diagnosis

Ataksia VestibulerAtaksia Vestibuler Ataksia SerebellarAtaksia SerebellarBeberapa hari-Beberapa hari-minggu kemudian minggu kemudian lenyaplenyapVertigoVertigoJatuh ke satu sisiJatuh ke satu sisiTampak deviasi bila Tampak deviasi bila menunjukmenunjukDipengaruhi posisi Dipengaruhi posisi kepalakepala

Lebih permanen Lebih permanen

Vertigo (-)Vertigo (-) (-)(-) (-)(-)

(-)(-)

BAEP / BERABAEP / BERA

ABR

Auditory Brainstem Response

Latency: Latency is the time from the stimulation onset to the peak point of a wave. The waveforms are called wave I, wave II, wave III, wave IV, wave V, wave VI and wave VII in order of appearance. The waves I, III and V are stable and have large amplitude. Depending on the patient, the peaks of the waves II, IV and V may not be obtained. The wave II may have an equivocal waveform and the waves IV and V may make a fused waveform.

Inter peak latency (IPL): By observing the difference in latency between the wave I and III, between the wave III and V, and between the wave I and V. The function of the auditory pathway can be examined

BAEPBAEP

A delayed I-III IPL indicates A delayed I-III IPL indicates abnormality between abnormality between the periphery the periphery and the medullaand the medulla. .

Long III-V IPL indicates abnormality Long III-V IPL indicates abnormality between between the medulla and the the medulla and the midbrainmidbrain..

Peripheral or Central Peripheral or Central Cause?Cause?

PeripheralPeripheral

Labyrinth or Labyrinth or vestibular nerve vestibular nerve dysfunctiondysfunction

RecurrentRecurrent Nystagmus-horizontalNystagmus-horizontal Position changePosition change Moderate to severe Moderate to severe

vertigovertigo

CentralCentral

Cerebellum or Cerebellum or brain stem brain stem dysfunctiondysfunction

ContinuousContinuous Nystagmus-verticalNystagmus-vertical Mild vertigoMild vertigo Non-positionalNon-positional

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CHARACTERISTICS OF PERIPHERAL CHARACTERISTICS OF PERIPHERAL AND CENTRAL VERTIGOAND CENTRAL VERTIGO

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Central Vestibular Central Vestibular DisordersDisorders

Brain stem lesionBrain stem lesion Basilar artery Basilar artery

migrainemigraine TIATIA StrokeStroke MSMS Cerebellar lesionsCerebellar lesions

Metastatic TumorMetastatic Tumor MeningiomaMeningioma

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Peripheral Vestibular DisordersPeripheral Vestibular Disorders

BPPVBPPV LabrynthitisLabrynthitis Meniere’s diseaseMeniere’s disease Acoustic NeuromaAcoustic Neuroma Motion sicknessMotion sickness CervicogenicCervicogenic Perilymphatic Perilymphatic

fistulafistula

Vestibular Vestibular neuronitisneuronitis

Semicircular canal Semicircular canal infectioninfection

Semicircular canal Semicircular canal water penetrationwater penetration

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Acute Dizziness: Important Acute Dizziness: Important Emergency Room Emergency Room ConsiderationsConsiderations

Characteristics of peripheral vertigo and Characteristics of peripheral vertigo and dizzinessdizziness

Characteristics of vertigo and dizziness of Characteristics of vertigo and dizziness of central origincentral origin

Recognizing stroke syndromes that may Recognizing stroke syndromes that may present with dizziness as a prominent present with dizziness as a prominent featurefeature

Treatment considerations in dizziness of Treatment considerations in dizziness of central origincentral origin

Treatment of peripheral vestibular Treatment of peripheral vestibular dysfunctiondysfunction

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Serious vertigo that is disabling Ataxia out of proportion to vertigo Vertigo longer than 4 weeks Changes in hearing Vertical nystagmus Focal neurological signs Systemic disease or psychological origin

Australian Family Physician Vol. 31, No 8, August 2002

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Head and Neck

Nystagmus– Oscillation of eyes on attempted fixation– Fast component is the direction of the nystagmus

and is towards the side of the lesion– Test in 4 directions– Must be sustained for more than a few beats

Dysarthria– Slurred or ‘scanning’ speech– Usually bilateral lesion– ‘Baby hippopotamus’ or ‘East Register Street is

opposite West Register Street’

Cerebellar HemorrhageCerebellar Hemorrhage

Sudden vertigo and nauseaSudden vertigo and nausea Vomiting associated with a headacheVomiting associated with a headache Inability to standInability to stand Nystagmus, nuchal rigidity, facial Nystagmus, nuchal rigidity, facial

paralysis, ataxia, dysrythmia, small paralysis, ataxia, dysrythmia, small reactive pupilsreactive pupils

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Acoustic NeuromaAcoustic Neuroma

Mild but constant hearing lossMild but constant hearing loss Dizziness with possible tinnitisDizziness with possible tinnitis Gradual onsetGradual onset Benign schwannoma of 8Benign schwannoma of 8thth CN CN Other CN findings as tumor growsOther CN findings as tumor grows Surgical excisionSurgical excision

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PengobatanPengobatan

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1. PENGOBATAN KAUSAL1. PENGOBATAN KAUSAL Kebanyakan kasus vertigo tidak diketahui Kebanyakan kasus vertigo tidak diketahui sebabnya, kalau penyebabnya diketahui sebabnya, kalau penyebabnya diketahui pengobatan kausal merupakan pilihan pengobatan kausal merupakan pilihan utamautama

2. PENGOBATAN SIMPTOMATIK2. PENGOBATAN SIMPTOMATIK

Pengobatan ini ditujukan pada dua gejala Pengobatan ini ditujukan pada dua gejala

utama yaitu rasa vertigo ( berputar, utama yaitu rasa vertigo ( berputar,

melayang ) dan gejala otonom (mual, melayang ) dan gejala otonom (mual,

muntah) Gejala yang paling berat pada muntah) Gejala yang paling berat pada

vertigo vestibuler fase akut, menghilang vertigo vestibuler fase akut, menghilang

beberapa hari karena ada kompensasibeberapa hari karena ada kompensasiBack

Terapi Simptomatik / Obat Terapi Simptomatik / Obat Anti VertigoAnti Vertigo

1) Ca entry Blocker

2) Antihistamin

3) Antikolinergik

4) Monoaminergik

5) Bensodiasepin

6) Antidopaminergik

7) Histaminik

8) Antiepileptik

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Mekanisme kerja obat anti Mekanisme kerja obat anti vertigovertigo

CALCIUM ENTRY BLOCKERCALCIUM ENTRY BLOCKER

Mengurangi aktivitas eksitatori SSP dengan Mengurangi aktivitas eksitatori SSP dengan menekan pelepasan glutamat dan bekerja langsung menekan pelepasan glutamat dan bekerja langsung sebagai depresor labirin, bisa untuk vertigo perifer sebagai depresor labirin, bisa untuk vertigo perifer dan sentral. dan sentral.

Obat : Flunarisin (Silum)Obat : Flunarisin (Silum)

ANTIHISTAMIN ANTIHISTAMIN

Efek antikolinergik dan merangsang inhibitori Efek antikolinergik dan merangsang inhibitori monoaminergik, akibatnya inhibisi nervus vestibularis. monoaminergik, akibatnya inhibisi nervus vestibularis. Obat : Obat : Sinarisin ( Merron ), dimenhidrinat (Dramamine), Sinarisin ( Merron ), dimenhidrinat (Dramamine), prometasin (Phenergan), meclizine, cyclizineprometasin (Phenergan), meclizine, cyclizine

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ANTIKOLINERGIK ANTIKOLINERGIK Mengurangi eksitabilitas neuron dengan Mengurangi eksitabilitas neuron dengan menghambat jaras eksitatori kolinergik ke nervus menghambat jaras eksitatori kolinergik ke nervus vestibularis, mengurangi firing rate dan respon vestibularis, mengurangi firing rate dan respon nervus vestibularis terhadap rangsang. nervus vestibularis terhadap rangsang. Obat : Obat : Skopolamin, atropinSkopolamin, atropin

MONOAMINERGIKMONOAMINERGIK

Merangsang jaras inhibitori-monoaminergik pada Merangsang jaras inhibitori-monoaminergik pada n. vestibularis sehingga eksitabilitas neuron n. vestibularis sehingga eksitabilitas neuron berkurang. berkurang.

Obat : Amphetamine, efedrinObat : Amphetamine, efedrin

BENZODIAZEPIN BENZODIAZEPIN

Menurunkan resting aktiviti neuronMenurunkan resting aktiviti neuron Back

ANTIDOPAMINERGIK (FENOTIASIN)ANTIDOPAMINERGIK (FENOTIASIN)

Bekerja pada CTZ dan pusat muntah di medula Bekerja pada CTZ dan pusat muntah di medula oblongata. oblongata. Obat : Clorpromazin (largactil), Obat : Clorpromazin (largactil), proclorperazine (Stemetil), Halloperidol proclorperazine (Stemetil), Halloperidol (Haldol)(Haldol)

HISTAMINIK HISTAMINIK

Inhibisi neuron polisinaptik pada nervus Inhibisi neuron polisinaptik pada nervus vestibularis lateralis. vestibularis lateralis. Obat : betahistinObat : betahistin

ANTIEPILEPTIKANTIEPILEPTIK

Karbamasepin, fenitoin pada temporal lobe Karbamasepin, fenitoin pada temporal lobe epilepsi dengan gejala vertigoepilepsi dengan gejala vertigo

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FlunarizineFlunarizine Calcium entry blockerCalcium entry blocker

Mengurangi aktivitas eksitatori SSP Mengurangi aktivitas eksitatori SSP dengan menekan pelepasan glutamatdengan menekan pelepasan glutamat

Meningkatkan aktivitas NMDA spesifik Meningkatkan aktivitas NMDA spesifik channelchannel

Depresor labirinDepresor labirin

Dosis satu tablet sehari, ½ tablet pagi ½ Dosis satu tablet sehari, ½ tablet pagi ½ tablet malamtablet malam

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Efek samping mengantuk dan rasa Efek samping mengantuk dan rasa lemas yang sifatnya sementara.lemas yang sifatnya sementara.

Kontra indikasi belum diketahui. Kontra indikasi belum diketahui. Keamanan penggunaan pada wanita Keamanan penggunaan pada wanita

hamil,ibu menyusui,dan anak belum hamil,ibu menyusui,dan anak belum diketahui.diketahui.

Lanjutan…………

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BetahistineBetahistine Analog histaminAnalog histamin Meningkatkan aliran darah Meningkatkan aliran darah

a.vertebrobasilera.vertebrobasiler Memperbaiki mikrosirkulasi telinga Memperbaiki mikrosirkulasi telinga

dalam dalam Menghambat neuron polisinaptikMenghambat neuron polisinaptik Dosis 1 tablet 3 kali sehariDosis 1 tablet 3 kali sehari Hati-hati pada penderita gastric ulcer, Hati-hati pada penderita gastric ulcer,

asma bronchiale, pheochromocytomaasma bronchiale, pheochromocytoma

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Drug-Induced DizzinessDrug-Induced Dizziness

Drugs that cause hypovolemia or Drugs that cause hypovolemia or decrease blood pressure decrease blood pressure (antihypertensives, tricyclics, (antihypertensives, tricyclics, psychotropics, muscle relaxants)psychotropics, muscle relaxants)

Ototoxic drugs (ASA, aminoglycosides)Ototoxic drugs (ASA, aminoglycosides) NSAIDs (including COX2 inhibitors)NSAIDs (including COX2 inhibitors) Alcohol - postural hypotension with Alcohol - postural hypotension with

high levels, vertigo when levels decline high levels, vertigo when levels decline

Zweig, MD

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Eaton, 2003

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DysequillibriumDysequillibrium

Is a feeling that a fall is Is a feeling that a fall is imminent and is characterized imminent and is characterized by unsteadiness or imbalance by unsteadiness or imbalance that occurs only when erect and that occurs only when erect and primarily involves the trunk and primarily involves the trunk and lower extremities rather than lower extremities rather than the head; the sensation the head; the sensation diappears when sitting or lyingdiappears when sitting or lyingEaton, 2003

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VERTIGOVERTIGO

DEFINISI:DEFINISI:Vertigo adalah perasaan penderita Vertigo adalah perasaan penderita merasa dirinya atau dunia berputarmerasa dirinya atau dunia berputar

ETIOLOGIETIOLOGI

1. Otologi:1. Otologi: 24-61% kasus24-61% kasus Benigna Paroxysmal Positional Vertigo (BPPV)Benigna Paroxysmal Positional Vertigo (BPPV) Meniere DeseaseMeniere Desease Parese N VIII Uni/bilateralParese N VIII Uni/bilateral Otitis MediaOtitis Media

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22. Neurologik. Neurologik 23-30% kasus23-30% kasus Gangguan serebrovaskuler batang otak/ Gangguan serebrovaskuler batang otak/

serebelumserebelum Ataksia karena neuropatiAtaksia karena neuropati Gangguan visusGangguan visus Gangguan serebelumGangguan serebelum Gangguan sirkulasi LCSGangguan sirkulasi LCS Multiple sklerosisMultiple sklerosis Malformasi ChiariMalformasi Chiari Vertigo servikal Vertigo servikal

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3. Interna:3. Interna: ++/- 33% karena gangguan kardio /- 33% karena gangguan kardio

vaskulervaskuler tekanan darahtekanan darah Aritmia kordisAritmia kordis Penyakit koronerPenyakit koroner InfeksiInfeksi HipoglikemiaHipoglikemia Intoksikasi Obat: Nifedipin, Intoksikasi Obat: Nifedipin,

Benzodiazepin, XanaxBenzodiazepin, Xanax,,

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RISK FACTORS FOR RISK FACTORS FOR TIA AND STROKE TIA AND STROKE

High Blood Pressure (2) High Blood Pressure (2) Elevated cholesterol (especially LDL) Elevated cholesterol (especially LDL) Smoking (1.7-2.3) Smoking (1.7-2.3) Family history of stroke or heart attack Family history of stroke or heart attack Age (male > 45, female > 55) Age (male > 45, female > 55) Overweight Overweight Sedentary life style Sedentary life style Diabetes Mellitus (2.7) Diabetes Mellitus (2.7) Collagen Vascular disease Collagen Vascular disease Heart problem such as atrial fibrillation (1.5) or old infarction (2.7) Heart problem such as atrial fibrillation (1.5) or old infarction (2.7) elevated homocysteine elevated homocysteine

(Whisnant (Whisnant et al.et al., 1996), 1996)