The treatment of acute vertigo

Cesarani A, Alpini D, Monti B, Raponi G

Neurol Sci 2004;24:S26-30.

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Introduction
Vertigo and dizziness are very common symptoms
in the general population
Prevalence rate: 5~10%
Particularly common in the individuals over 40
years of age
The first reason for a medical visit in patients
over 65 years

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 Two main group of acute vertigo

Spontaneous vertigo
Provoked vertigo ( paroxysmal positional
vertigo, PPV, BPPV )

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Acute spontaneous vertigo

acute spontaneous unilateral vestibular failure,
which means sudden asymmetrical vestibular
functioning.
4 stages

Stage 1: irritation
Stage 2: sudden loss of paralysis of the system
Stage 3: central compensation
Stage 4: recovery

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 Stage 1: irritation
Spontaneous nystagmus beats towards the affected side
Normal caloric reaction ( cold waterbeat to opposite
site; warm water beat to ipsilateral site; nystagmus last
for 3 mins)

Stage 2: sudden loss of paralysis of the system

Stage 3: central compensation
Stage 4: recovery

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 Stage 1: irritation
Stage 2: sudden loss of paralysis of the system

Typical rotatory vertigo

Spontaneous nystagmus beats towards the normal side
Caloric reaction is absent or reduced at the affected
side
Hospitalization is common

Stage 3: central compensation

Stage 4: recovery
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Stage 1: irritation
Stage 2: sudden loss of paralysis of the system

Stage 3: central compensation

Progressive decrease in vertigo and nystagmus

Provocative maneuvers (esp: head shaking)reveal vertigo
and nystagmus

Stage 4: recovery

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Stage 1: irritation
Stage 2: sudden loss of paralysis of the system
Stage 3: central compensation

Stage 4: recovery
Nystagmus towards the affected side

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 Early phase
Stage1&2

Nausea and vomiting

Rotatory vertigo is present in every position of the head
and body, slightly less when lying on the SS.
The first mechanism of recovery is internuclear
inhibition of the vestibular responses.
Pharmacotherapy vs physical therapy

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Aims of therapy
Decreasing the neurovegetative S/S
Decreasing antigravitary failure of the affected
side
Decreasing oscillopsia due to nystagmus
Decreasing internuclear inhibition that decreases
progression of functional compensation
Activating sensory substitution phenomena
Re-activating coordination
Decreasing spatial disorientation ( vertigo)

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Pharmacotherapy

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Physical therapy
Vestibular electrical stimulation ( VES)
Exercise

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Vestibular Electrical Stimulation

The first step of physical therapy
Aimed to reduce antigravity failure and to increase
proprioceptive cervical sensory substitution.
TENS; on paravertebral muscle opposite to the affected
side and on the trapezius of the affected side.
At 1 hr per day at least
The first half hour: pt lye on the SS, in the light, and try
to keep their eyes open
The other half hour: practice activities in upright position
and walking during VES

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Exercise in bed
Twice a day, 20-30 mins per session

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Exercise in sitting(1)
Performed during VES and wearing visual prisms

(saccade)

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Exercise in sitting(2)

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Paroxysmal Positional Vertigo(1)

Sudden attacks of vertigo precipitated by certain head
positions.
Rolling over in the bed,reaching for an object from the top
shelf, washing the hair
Vertigo is of short duration ( < 1min )
Etiology:
Litiasis theory, originally describe by Schucknecht in1974
Degeneration of the salt-like crystals (otoliths) in the
utricle which break free and float into or attach to
semicircular canals.
Proprioceptive mismatch btw the general proprioception (from
muscles, ligament and joints) and special proprioception (from
maculae and cristae); spino-cerebello-vestibular circuitry.

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Paroxysmal Positional Vertigo(2)

Two main types
Dix-Hallpike maneuver elicited
Head hyperextension and rotation to AS
Induced typical horizontal-rotatory geotropic (towards the
ground) nystagmus
Nystagmus appears some seconds delay
Habituation phenomena
MacClure maneuver elicited
Pt supine, rolling the head from side to side
Pure horizontal geotropic and ageotropic nystagmus

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Treatment for PPV

Semont maneuver
Epley maneuver
Personal maneuver for PPV elicited by DixHallpike positioning ( Epley modified)
Lempert maneuver

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post. Semicircular
canal lithiasis
80~90%effective

horizontal semicircular lithiasis

Semont maneuver
Right ear lat canal PPV
1. Head turn
towards left
side(SS)

1&4

2. Lying on R side,
head is rotated
upward 105,
3mins

3. Lying on L side,
head is rotated
downward 195,
3 mins

4. Slowly sit-up

http://www.neurology.org/cgi/content/full/63/1/150/DC1
(video 1)
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Epley maneuver
Left ear post. Canal PPV

Head rotate
to left 45

Each stage wait 30 s

http://www.neurology.org/cgi/content/full/63/1/150/DC1
(video 2)
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Modified Epley
Left ear BPPV

30 sec

30 sec

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Lempert maneuver
Right ear PPV

30~60 sec

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Thank you for your attention

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