2. Neurologic Origins of Dizziness & Vertigo

3. Clinical presentations of Dizziness or Vertigo that is of Neurologic Origin  Neurologically mediated dizziness can be reported as: 1. Presyncope 2. Disequilibrium 3. True Vertigo 4. Confusion or disorientation

4. Characteristics of Neurologically Mediated Dizziness A. Episodic  Multiple sclerosis  Migraine aura  Auras of seizure disorders  Posterior cerebral circulation transient ischemic attacks B. Unremitting & progressively worsening dizziness  Brain tumor

5. Characteristics of Neurologically Mediated Dizziness C. Sudden onset in patient with risk of atherosclerosis  Thromboembolism to the vertebal or basilar artery D. Movement or position-provoked dizziness  Presyncope when rising from supine position – orthostatic hypotension  Presyncope from lateral neck rotation – carotid sinus hypersensitivity syndrome

6. the Diagnostic Workup  Nature and extent of diagnostic workup depend on the differential and provisional diagnoses  History & physical examination  Imaging studies  VNG, rotational chair testing, and posturography  Cardiovascular evaluation  Electroencephalogram (EEG)

7. Special Neurologic Conditions Associated with Dizziness or Vertigo 1. Cerebrovascular disease 2. Multiple sclerosis 3. Paraneoplastic neurological syndromes 4. Migraine 5. Mal de Débarquement 6. Spinocerebellar and episodic ataxias 7. Autonomic insufficiency 8. Postconcussive syndrome 9. Medication- and substance-induced dizziness

8. 1. Cerebrovascular disease - STROKE  Sudden onset of neurologic deficit that is caused by: 1. Hemorrhage (hemorrhagic stroke) 2. Cessation of blood flow to a brain region (ischemic stroke)  Related to cerebrovascular atherosclerosis, vertebrobasilar insufficiency (VBI)  Can cause permanent or transient damage to the brain

9. 1. Cerebrovascular disease - STROKE  Effects when the cerebellum, vestibular nuclei, & connections are damaged:  Dizziness, vertigo, or unsteadiness  Diplopia, dysarthria, bilateral weakness, nausea, abrupt onset  Duration:  Few minutes with transient ischemic attacks  Days to months with permanent ischemia

10. 2. Multiple Sclerosis  Chronic illness characterized by recurrent episodes of demyelination of nerve fibers in the CNS  Symptoms:  Fatigue  Visual deficits  Numbness  Vertigo or unsteadiness  Dysarthria  Facial nerve pain  Treatment for episodic vertigo – vestibular suppressant (meclizine or diazepam)

11. 3. Paraneoplastic Neurologic Syndromes  Remote effects of cancer on the  CNS,  Peripheral nervous system,  Autonomic nervous system, and  Muscles  Partially triggered by autoimmune processes

12. 3. Paraneoplastic Neurologic Syndromes  Paraneoplastic cerebellar degeneration  Most often caused by gynecologic malignancy, lung carcinoma, Hodgkin’s lymphoma  Patients may present with:  Probable VNG findings: