seizure, epilepsy, true vertigo, neurology

seizure,true vertigo.pptx

1. Seizure and Epilepsy Dr Elahe Taghvaei neurologist

2. What is a seizure?   A seizure is an abnormal electrical discharge that occurs in your brain. Usually brain cells, or neurons, flow in an organized fashion along the surface of your brain. A seizure occurs when there is an excess of electrical activity. Seizures can cause symptoms such as muscle spasms, limb twitches, and loss of consciousness. They can also lead to changes in feeling and behavior .

3. Seizure versus Epilepsy S eizure is the an event Epilepsy is the disease associated with spontaneously recurring seizures

4. seizure Unprovoked seizures have what are considered natural causes, such as genetic factors or metabolic imbalances in your body . Provoked Seizures that stem from an identifiable cause( Head/brain damage,stroke , infection of the brain,…)

5. Epilepsy Definition Epilepsy is a disease of the brain defined by any of the following conditions A least two unprovoked (or reflex) seizures occurring >24 h apart 2. One unprovoked (or reflex) seizure and a probability of further seizures similar to the general recurrence risk (at least 60%) after two unprovoked seizure occurring over the next 10 years 3. Diagnosis of an epilepsy syndrome

6. Increased recurrence risk of a seizure Adults with an unprovoked first seizure should be informed that sz recurrence risk is greatest early within the first 2 years (21%–45%) , and clinical variables associated with increased risk may include: Prior brain insult Epileptiform EEG Abnormal CT/MRI Nocturnal seizure

7. Small recurrence risk of a seizure These are not Epilepsy because there is small risk of a seizure in the absence of a precipitating factor: Febrile seizures in children age 0.5 – 6 years old Alcohol-withdrawal seizures Metabolic seizures (sodium, calcium, magnesium, glucose, oxygen) Toxic seizures (drug reactions or withdrawal, renal failure) Convulsive syncope Acute concussive convulsion Seizures within first week after brain trauma, infection or stroke

8. Reflex Epilepsies A group of epilepsy syndromes in which a certain trigger or stimulus brings on seizures . The trigger can be something simple in the environment or something more complex . Simple environmental triggers include sensations like touch, light or movement,… photosensitive epilepsy, eating epilepsy,reading epilepsy,...

9. Acute Symptomatic Epilepsy Acute symptomatic seizures are events, occurring in close temporal relationship with an acute CNS insult, which may be metabolic, toxic, structural, infectious, or due to inflammation. The interval between the insult and seizure may vary due to the underlying clinical condition . Stroke TBI Anoxic encephalopathy Intracranial surgery First identification of subdural hematoma Presence of an active CNS infection During an active phase of multiple sclerosis or other autoimmune disease Acute symptomatic seizures are unlikely to be recurrent Unprovoked seizures are often recurrent

10. Epidemiology Epilepsy affects 50 million  people around the world, according to the World Health Organization (WHO) and nearly 3.5 million  people in the United States, per the Centers for Disease Control and Prevention (CDC). Anyone can develop epilepsy, but it most commonly onsets in young children and older adults. According to  research published in 2021 , men develop epilepsy more often than women, possibly because of higher exposure to risk factors like alcohol use and head trauma .

11. Types of seizures Seizures are classified based on the parts of the brain involved. They include focal and generalized seizures. Focal seizures  occur when abnormal electrical activity starts in one area of the brain. This used to be called a partial seizure. Generalized seizures  start in both sides of the brain. Sometimes, a focal seizure can become generalized if it spreads.

12. Types of focal seizures Types include: focal aware seizures focal impaired awareness seizure focal to bilateral tonic- clonic seizures gelastic and dacrystic seizures

13. Focal aware seizure During a focal aware seizure, previously called a  simple focal seizure , you do not lose consciousness . You’re aware of yourself and surroundings. Symptoms can include one or more of the following : unusual head or eye movements dilated pupils tightened muscles numbness tingling sensation of crawling on the skin hallucinations nausea sweating facial flushing vision changes difficulty speaking sensation of  déjà vu This seizure may last between a few seconds and 2 minutes .

14. focal impaired awareness seizure A focal impaired awareness seizure happens when your consciousness is partially or completely lost . It used to be called a complex focal seizure or  complex partial seizure . You won’t be aware of yourself and surroundings, but you’ll seem awake. Possible symptoms include: inability to respond blank staring appearance of daydreaming lip smacking screaming crying or laughing repeating words or phrases performing involuntary physical actions, like jerking becoming rigid and still This seizure typically lasts between 1 and 2 minutes. After the seizure, you may feel sleepy and confused.

15. Focal to bilateral tonic- clonic seizures This seizure occurs when a focal impaired awareness seizure becomes generalized or spreads to both sides of the brain. It used to be called a secondary generalized seizure. It often causes clonic jerking and tonic muscle stiffening . Jerking arm and leg movements can occur along with facial twitching , impaired control of the bowel or bladder, and repeated flexing and relaxing of the muscles. Other symptoms include: loss of consciousness falling to the floor crying groaning biting your tongue or inside of cheek difficulty breathing

16. Gelastic and dacrystic seizures These seizures begin in the hypothalamus , which is located at the base of the brain. Gelastic seizures , or laughing seizures, involve involuntary laughing. Dacrystic seizures cause involuntary crying. You don’t lose consciousness during these seizures.

17. Types of generalized seizures generalized tonic- clonic seizures (GTC) tonic seizures clonic seizures absence seizures myoclonic seizures atonic seizures infantile or epileptic spasms

18. Tonic- Clonic (Grand Mal) Seizures Aura The seizure may start with a simple or complex partial seizure known as an aura. The person may experience abnormal sensations such as a particular smell, vertigo, nausea, or anxiety. If the person is familiar with having seizures, they may recognize the warning signs of a seizure about to begin. Tonic Activity When the tonic- clonic seizure begins, the person loses consciousness and may fall. Strong tonic spasms of the muscles can force air out of the lungs, resulting in a cry or moan, even though the person is not aware of their surroundings. There may be saliva or foam coming from the mouth. If the person inadvertently bites their tongue or cheek, blood may be visible in the saliva. Stiffness of the chest muscles may impair breathing, the person’s face may look bluish or gray, and he or she may make gasping or gurgling sounds. Clonic Activity Jerking movements affect the face, arms and legs, becoming intense and rapid. After one to three minutes, the jerking movements slow down and the body relaxes, sometimes including the bowel or bladder. The person may let out a deep sigh and return to more normal breathing. After the Seizure (Postictal Period) After a seizure, the person may remain unconscious for several minutes as the brain recovers from the seizure activity. He or she may appear to be sleeping or snoring.

19. Tonic seizures A tonic seizure only causes muscle stiffening . It sometimes occurs during sleep and involves muscles in the: back legs arms Tonic seizures may cause people to fall down if they are standing or walking when the seizure occurs.

20. Clonic seizures These seizures only involve repeated muscle jerking , or clonic movements .

21. Absence seizures previously called petit mal seizures, are often mistaken for daydreaming. There are two types: Typical absence seizure : This seizure causes sudden symptoms like blank staring and fluttering eyelids. It generally lasts less than 10 seconds. Atypical absence seizure : This seizure causes symptoms that develop slowly, including blank staring, eye blinking, hand motions, and fluttering eyelids. It usually lasts 20 seconds or longer and is often part of a neurodevelopmental epilepsy syndrome. Absence seizures are more common in children than in babies or adults.

22. Myoclonic seizures A myoclonic seizure causes sudden muscle jerking without impaired consciousness. It typically involves muscles on both sides of the body. Generally , these seizures last for 1 or 2 seconds. They often happen multiple times within a day or several days.

23. Atonic seizures In an atonic seizure, or drop attack, you suddenly lose muscle tone . Symptoms include: falling from standing position sudden head dropping inability to respond

24. Infantile or epileptic spasms An epileptic spasm involves brief extending or flexing of the arm, leg, or head . It commonly affects children younger than 2 years old. If it occurs in an infant, it’s often called an  infantile spasm . These spasms last 1 to 3 seconds. They can happen several times a day.

25. status epilepticus A seizure that lasts longer than 5 minutes , or having more than 1 seizure within a 5 minutes period, without returning to a normal level of consciousness between episodes is called status epilepticus. This is a medical emergency that may lead to permanent brain damage or death . Convulsive status epilepticus Nonconvulsive status epilepticus

26. Aura Some seizures cause symptoms just before they start. Warnings sign can include: a sense of deja vu a feeling of confusion or diminished awareness twisting of the face, arm, or leg any symptom pattern that usually precedes your seizures If you notice these warning signs, here’s what you should do: Find a safe area without hazardous items or furniture. Loosen clothing around your neck. Let someone know what is happening. If you’re driving, pull over. If you’re near water or a heat source, like a campfire, move away. Follow your seizure action plan. Consider lying down or sitting.

27. febrile seizure   A  febrile seizure  occurs when a child between 6 months and 5 years old has a fever. It may be the first sign that a child is sick. There are two types: Simple febrile seizure .  This lasts less than 15 minutes. Only one seizure occurs in 24 hours. Complex febrile seizure .  This lasts more than 15 minutes. It may happen multiple times in 24 hours . It's not recommended that your child is given a prescription of regular medicines to prevent further febrile seizures.

28. febrile seizure

29. Conditions that mimic epileptic seizures Some disorders may cause symptoms that look like epilepsy. However, these disorders require different treatment and care. They include : Syncope TIA Nonepileptic events (NEE) Abnormal movements Tics Panic attack Basilar migraine,…

30. DDx-Nonepileptic events (NEE) NEE, or  pseudoseizures , are associated with extreme stress and psychological disorders. They aren’t caused by abnormal changes in the brain’s electrical activity. These seizures most commonly affect people who have: epilepsy post-traumatic stress disorder (PTSD) anxiety disorder major depressive disorder personality disorders NEE may look like GTC seizures. But unlike GTC, they cause muscle jerking that’s out of phase and not rhythmic. Nonepileptic events are more common in adults than in babies and children.

31. P sychogenic nonepileptic seizures (PNES) and epileptic seizures (ES) Signs and symptoms favoring PNES Signs and symptoms favoring ES Differences between PNES and ES irrespective of types of events Duration of longer than 10 min   Vocalization during or after seizures, complex, with affective content Vocalization at the beginning, primitive, has no emotional expression Ictal crying   Occurrence from preictal pseudosleep Occurrence from sleep Ictal eye closure   Signs and symptoms discriminating Hypermotor and Focal Motor PNES from ES Side-to-side head or body movement (compared with generalised tonic clonic seizures only) Postictal confusion Pelvic thrusting (frontal lobe partial seizures excluded) Postictal stertorous (generalised tonic clonic seizures only) Fluctuating course   Asynchronous jerks (frontal lobe partial seizures excluded)

32. DDX-Tics Tics are repeated patterns of involuntary movement that happen while a person is conscious . They usually affect one side of the face, but they can affect the neck, shoulders, or other areas of the body. They can come in the form of physical tics or verbal tics. Some conditions involving tics include: transient tic disorder facial tic disorder chronic motor tic disorder Tourette syndrome While tics can be suppressed temporarily by the person experiencing them, they often have to be expressed once the person relaxes.

33. DDx -syncope Identifiable triggers are associated with syncope. seizures tend to have a longer duration than syncope. Seizures are followed by postictal confusion and significant fatigue, although brief periods of confusion have been reported with convulsive syncope . common features of convulsive syncope that are not common in seizures include a period of presyncope with prodrome , pallor, duration less than one minute , and fixed or upward eye deviation. common features of a seizure, that are not common in syncope, can include tongue biting, prodromal cry, incontinence, duration often a few minutes, and lateral eye deviation . Accurate diagnosis is often challenged by the patient’s amnesia of the events, lack of bystander presence/account, and discordance among clinician opinions

34. Comparison of clinical features in cardiogenic syncope versus seizure disorders clinical features Cardiogenic syncope Seizure disorders Loss of consciousness Typical Common Episode duration Seconds Minutes Involuntary movements Common Typical Amnesia Yes Yes Arrhythmia Common Rare* Electroencephalogram Slow waves Flattening Focal or general spike activity Responsive to AEDs No Often Short term mortality† High Low

35. DDx -Panic attack A panic attack or anxiety attack is an extreme form of anxiety that causes severe physical reactions. These can include heart palpitations, sweating, trembling and shaking, headaches, dizziness, hot flashes and chills . They are accompanied with a feeling of intense fear . Many of these symptoms can appear similar to epileptic seizures. However a panic attack is not the same as an epileptic seizure (seizures are caused by unusual electrical discharges in the brain).   panic attacks are generally longer in duration than seizures ; ictal episodes are more stereotyped , whereas panic episodes are likely to vary more in presentation ; although seizure disorders may initially present with fear/anxiety, they may progress to the more classic symptoms (e.g., olfactory auras, aphasias, amnestic features, motionless state, visceral automatisms); initial presentation of these classic epileptic features (i.e., before the fear/panic feelings) suggests seizures; panic disorder is more likely associated with agoraphobia (50% of cases); panic disorder has stronger familial links (25% for first-degree relatives); panic disorder can be worsened by emotional distress; presence of temporal lobe lesions on imaging can indicate epilepsy; and some treatments for panic disorder can worsen seizures (e.g., tricyclic antidepressants).  If the presentation is suggestive of epilepsy, EEG examination may be required to identify the characteristic spike/wave pattern of seizure discharge. A full evaluation for epilepsy may require 24-hour EEG and video monitoring or intracerebral depth electrodes with subdural grid arrays, as these procedures can sometimes identify abnormal electrical discharges not observed on routine EEG. 

36. DDx -TIA TIA is caused by a temporary disruption in the blood supply to a part of the brain.  TIA can cause sudden symptoms that are very similar to a stroke – for example, speech and visual disturbance and numbness or weakness in the arms, legs, and face TIA last a few minutes to a few hours and fully resolve within 24 hours Negative symptoms , usually maximal at onset: for example, numbness, weakness, visual loss. Transient diplopia and monocular visual loss are often due to TIA   Seizure is a condition due to aberrant electrical discharges involving the cerebral cortex The sign and symptoms of a seizure include temporary confusion, a staring spell, uncontrollable jerking movements of arms and legs, loss of consciousness, anxiety, fear, or deja vu . Positive symptoms including painful sensory disturbance, limb jerking, head turning, dystonic posturing, lip smacking. Loss of awareness and amnesia for event unless simple partial seizures Postictal negative symptoms ( eg , Todd's paresis) may persist for days Associated symptoms : Tongue biting (especially lateral), incontinence , muscle pains, exhaustion or disorientation, headache follow

37. What causes seizures in different age groups? Any event or condition that disrupts the brain can cause seizures. The causes of epilepsy are age related. Newborns : A lack of oxygen at birth Low blood sugar, calcium, or magnesium, or problems with other electrolyte levels Malformations of the brain Metabolism dysfunction Intracranial hemorrhage Drug use by the newborn’s mother Infants and Children : Infection Fever (febrile seizures) Brain tumour (rare) Children and Adults: Genetic predisposition Trauma to the head Down’s syndrome, tuberous sclerosis, neurofibromatosis, Angelman syndrome, or other congenital conditions Progressive brain disease (rare) Seniors: Alzheimer’s disease Stroke Trauma Sometimes, the cause of a seizure is unknown.

38. What triggers an epileptic seizure? Some people identify things or situations that trigger their seizures. A few of the most common known triggers are: lack of sleep illness or fever stress bright lights, flashing lights, or patterns caffeine, alcohol or alcohol withdrawal, medications, or illegal drugs skipping meals, overeating, or specific food ingredients very low blood sugar head injury changes in your hormones, such as during a woman’s menstrual cycle Identifying triggers isn’t always easy. A single incident doesn’t always mean something is a trigger. Often, a combination of factors triggers a seizure.

39. Complications and risks of seizures Epileptic seizures disrupt the electrical activity of your brain, which can directly or indirectly affect many parts of your body. Potential complications of epilepsy include: falls and slips tongue lacerations (from biting) pregnancy complications drowning (while in water) motor vehicle accidents (while driving ) brain damage from prolonged and uncontrolled seizures(learning difficulty ,…) choking on food or saliva medication side effects depression sudden unexpected death (SUDEP)

40. sudden unexpected death in epilepsy (SUDEP ) SUDEP is an epilepsy-related death not caused by drowning, injury, or another known cause. Pauses in breathing, airway obstruction, and abnormal heart rhythm are thought to contribute. SUDEP is more common in people with epilepsy that is not well managed . Taking all your medication as prescribed and visiting your doctor regularly can help you minimize your risk.

41. How is epilepsy diagnosed? Your medical history and symptoms will help your doctor decide which tests will be helpful. They’ll likely give you a neurological examination to test your motor abilities and mental functioning. To diagnose epilepsy, other conditions that cause seizures should be ruled out . Blood tests may be used to look for: signs of infectious diseases liver and kidney function blood glucose levels Electroencephalogram (EEG)  is the most common test used to diagnose epilepsy. It’s a noninvasive and painless test that involves placing electrodes on your scalp to search for abnormal patterns in your brain’s electrical activity. In some cases, the test is performed while you sleep. Imaging tests can reveal tumors and other abnormalities that can cause seizures. These tests might include: CT scan MRI positron emission tomography (PET) single-photon emission computerized tomography Epilepsy is usually diagnosed if you have seizures, but there’s no apparent or reversible cause.

42. How is epilepsy treated? Treatment for epilepsy may help you have fewer seizures or stop seizures completely. Some treatment options include: Anti-epileptic (anticonvulsant, antiseizure ) drugs .  Anti-epileptic medications can help reduce the number of seizures you have. In some people, the seizures eliminate. Levetiracetam lamotrigine   topirmate   valproic acid carbamazepine  ethosuximide phenytoin carbamazepine Vagus nerve stimulation .   This device  is surgically placed under the skin on your chest and electrically stimulates the nerve that runs through your neck to prevent seizures. Ketogenic diet .  According to the Epilepsy Foundation, more than half  of children who do not respond to medications benefit from the ketogenic diet, which is a high fat and low carbohydrate diet. Brain surgery .  The area of the brain that causes seizure activity can be removed or altered if you and your healthcare team determine it’s the right treatment for your condition. One treatment that may be more widely available in the future is deep brain stimulation . It involves implanting electrodes into your brain and a generator into your chest. The generator sends electrical impulses to your brain to help decrease seizures.

43. Resolved epilepsy Epilepsy is considered to be resolved for individuals who had an age-dependent epilepsy syndrome but are now past the applicable age or those who have remained seizure-free for the last 10 years , with no seizure medicines for the last 5 years . but it does not guarantee that epilepsy will never come back If seizure-free for a few years,Then relapse risk is relatively low.

44. True vertigo

45. Anatomy Balance is controlled by the cerebellum , which receives input from the vestibular nuclei in the brain stem .  This in turn receives input from the visual pathway, proprioception and inner ear . The vestibular apparatus of the inner ear consists of three semicircular canals , and two otolith organs called the utricle and the saccule .  The utricle and saccule contain hair cells embedded in calcium carbonate crystals. These cells control vertical and non-rotational movements. Receptors in the semicircular canals respond to the position of the head. When the head tilts, receptors on the ipsilateral ear are stimulated and receptors in the contralateral ear are inhibited. These send impulses to the brain stem and cerebellum to control balance. Any disruption of this pathway can lead to vertigo .

46. True vertigo vs dizziness Dizziness is an altered sense of spatial orientation, a distortion of where we are within a space and like your balance just feels off. lightheadedness or faintness a false sense of spinning unsteadiness a loss of balance a feeling of floating Vertigo , on the other hand, is truly the sensation of self- movement or the movement of your surroundings – it's a spinning sensation.

47. Types of vertigo Peripheral vertigo is the most common  type of vertigo. It occurs as a result of a problem in the inner ear , or the vestibular nerve ,which controls balance. Central vertigo refers to problems within your brain or brainstem .

48. C auses of peripheral vertigo The most common causes of vertigo seen in primary care are benign paroxysmal positional vertigo ( BPPV ), vestibular neuronitis (VN) and Ménière’s disease . These peripheral causes of vertigo are benign , and treatment involves reassurance and management of symptoms . peripheral vertigo is usually more severe than central vertigo.

49. C auses of central vertigo Central vertigo can be caused by a variety of different conditions, including: stroke brain tumor migraine traumatic brain injury infection multiple sclerosis While most of the causes of vertigo are benign, more serious causes , including CVAs, MS, tumours need to be considered ,particularly in patients who are older or have risk factors for vascular diseases.

50. Approach to a patient with rue vertigo History Physical examination A careful history and physical examination can distinguish between central or peripheral causes of vertigo.

51. History It is important to differentiate vertigo from other non-rotational forms of dizziness . Once the diagnosis of vertigo is determined, this needs to be differentiated into a central or peripheral subtype . More serious central causes, such as cerebrovascular accidents (CVAs), tumours and multiple sclerosis (MS), need to be considered. Central causes are suspected if the patient presents with associated neurological symptoms such as weakness, dysarthria, sensory changes, ataxia or confusion . It may be difficult to distinguish between central and peripheral causes in patients who present with vertigo as their only symptom. Risk factors for vascular disease, including smoking, diabetes, obesity, hypertension and hypercholesterolaemia , need to be assessed to rule out CVAs, which can lead to vertigo from ischemia or infarction . Peripheral pathology is associated with symptoms of nausea, vomiting and hearing loss . Vertigo can be triggered by a change in the position of the head , recent upper respiratory tract infection (URTI), stress or trauma . Patients who experience anxiety or panic attacks can have vertigo as a result of hyperventilation .   Loud noises can precipitate vertigo in patients with peripheral causes in a phenomenon called Tullio phenomenon .  Medications, including frusemide , salicylates and antihypertensive agents, can affect the vestibular system, which in turn causes vertigo. Perilymphatic fistula should be considered if there is a history of recent head injury. Vertigo with hearing loss is seen in labyrithitis and Ménière’s disease, whereas hearing loss is not seen in benign paroxysmal positional vertigo (BPPV) and vestibular neuronitis (VN).

52. Distinguishing Characteristics of Peripheral vs. Central Causes of Vertigo Feature Peripheral vertigo Central vertigo Nystagmus Combined horizontal and torsional; inhibited by fixation of eyes onto object; fades after a few days; does not change direction with gaze to either side Purely vertical, horizontal, or torsional; not inhibited by fixation of eyes onto object; may last weeks to months; may change direction with gaze towards fast phase of nystagmus Imbalance Mild to moderate; able to walk Severe; unable to stand still or walk Nausea, vomiting May be severe Varies Hearing loss, tinnitus Common Rare Nonauditory neurologic symptoms Rare Common

53. Typical Duration of Symptoms for Different Causes of Vertigo Duration of episode Suggested diagnosis A few seconds Peripheral cause: unilateral loss of vestibular function; late stages of acute vestibular neuronitis; late stages of Ménière’s disease Several seconds to a few minutes Benign paroxysmal positional vertigo; perilymphatic fistula Several minutes to one hour Posterior transient ischemic attack; perilymphatic fistula Hours Ménière’s disease; perilymphatic fistula from trauma or surgery; migraine; acoustic neuroma Days Early acute vestibular neuronitis*; stroke; migraine; multiple sclerosis Weeks Psychogenic (constant vertigo lasting weeks without improvement)

54. Associated Symptoms for Different Causes of Vertigo Symptom Suggested diagnosis Aural fullness Acoustic neuroma; Ménière’s disease Ear or mastoid pain Acoustic neuroma; acute middle ear disease (e.g., otitis media, herpes zoster oticus) Facial weakness Acoustic neuroma; herpes zoster oticus Focal neurologic findings Cerebellopontine angle tumor; cerebrovascular disease; multiple sclerosis (especially findings not explained by single neurologic lesion) Headache Acoustic neuroma; migraine Hearing loss Ménière’s disease; perilymphatic fistula; acoustic neuroma; cholesteatoma; otosclerosis; transient ischemic attack or stroke involving anterior inferior cerebellar artery; herpes zoster oticus Imbalance Acute vestibular neuronitis (usually moderate); cerebellopontine angle tumor (usually severe) Nystagmus Peripheral or central vertigo Phonophobia, photophobia Migraine Tinnitus Acute labyrinthitis ; acoustic neuroma; Ménière’s disease

55. Physical examination Physical examination involves Neurological examination Cardiovascular examination eye and ear examination

56. physical examination A physical examination can assist in differentiating between central and peripheral subtypes of vertigo. Examination should involve the following: Ear examination : an otoscopic examination should be performed to visualise the tympanic membranes for any vesicles that can be seen in a  Herpes zoster  infection or retraction pockets as seen in cholesteotoma .   Vertigo triggered by pushing on the tragus or with the Valsalva manoeuvre is seen in a perilymphatic fistula. A hearing assessment should be performed. Eye examination : eyes need to be examined for nystagmus and papilledema. Nystagmus is quick, jerky, involuntary movements of the eye. Vertical nystagmus is only seen if the cause is central.Nystagmus due to central causes may be horizontal, rotational or vertical, and does not disappear on fixing the gaze.  Nystagmus in the peripheral type disappears with fixation of the gaze. Cardiovascular examination : pulse, blood pressure, heart rate and rhythm should be checked. Orthostatic changes in systolic blood pressure (e.g., a drop of 20 mm Hg or more) and pulse (e.g., increase of 10 beats per minute) in patients with vertigo upon standing may identify problems with dehydration or autonomic dysfunction. Carotid examination to identify bruits (in the case of a CVA) is necessary. Further imaging to rule out CVA can be performed if this is clinically suspected.

57. NEUROLOGIC EXAMINATION Neurological examination : initially, a focused neurological examination including gait, balance and coordination needs to be performed. A gait and balance assessment (Romberg’s sign and the heel-toe test ),  and examination for cerebellar signs can exclude central causes . Patients with peripheral vertigo have impaired balance but are still able to walk, whereas patients with central vertigo have more severe instability and often cannot walk or even stand without falling.

58. Dix- Hallpike maneuver If your doctor suspects BPPV, they may perform a Dix- Hallpike maneuver. To perform the Dix- Hallpike maneuver, the patient initially sits upright . The examiner should warn the patient that the maneuver may provoke vertigo. The examiner turns the patient’s head 30 to 45 degrees to the side being tested (A). The patient keeps his or her eyes open and focused on the examiner’s eyes or forehead. Then, as the examiner supports the patient’s head, the patient quickly lies supine (within two seconds), allowing the neck to hyperextend slightly and hang off the edge of the examining table 20 to 30 degrees past horizontal (B). After a two- to 20-second latent period , the onset of torsional upbeat or horizontal nystagmus denotes a positive test for benign paroxysmal positional vertigo. The episode can last 20 to 40 seconds. Nystagmus changes direction when the patient sits upright again.

59. Head impulse test The patient is asked to look at the examiner’s nose and the examiner quickly turns the patient’s head 10–20 degrees . It is abnormal if eyes move rapidly and repetitively, failing to re-fixate to the examiner’s nose. A positive test indicates disrupted vestibule-ocular reflex .

60. Benign paroxysmal positional vertigo BPPV is the most common cause of vertigo in clinical practice. It is caused by an accumulation of calcium crystals in the posterior semicircular canal. These crystals affect the movement of the endolymph in the semicircular canals, which causes vertigo. The classic symptoms of BPPV are brief episodes of vertigo , associated with nausea and nystagmus. The episodes of vertigo are triggered by rapid changes in the position of the head.   Symptoms can last for weeks and recur after remission. Unfortunately the recurrence rate of BPPV is 15 - 30% per year. It can follow after vestibular neuritis, head trauma, prolonged bed rest and Meniere’s disease, but more than 90% of cases are idiopathic. Nystagmus seen in BPPV has a rotational nature. The Dix− Hallpike manoeuvre is used to diagnose BPPV . In contrast, the Epley manoeuvre can be used to treat BPPV This procedure is performed in an attempt to dislodge the otoliths from the semicircular canals .

61. Epley manoeuvre Box 1. Epley manoeuvre for treatment of BPPV Sit the patient on the bed. With the neck hyperextended and laterally rotated to 45 degrees, the patient is asked to lie supine. The patient is required to maintain the supine position for one minute. The head is turned to the opposite side with lateral rotation of 45 degrees, and remains in this position for one minute. The head, chest and pelvis are tilted downwards to 135 degrees (almost prone), and this position is maintained for one minute. Quickly sit the patient upright with their head tilted to the affected side. This manoeuvre should not be performed in patients with neck injury, carotid stenosis and heart disease 1

62. Labyrinthitis An inner ear infection causes this form of vertigo. As a result, it often occurs along with other symptoms such as fever and earache( preceded by a viral infection ). The duration of symptoms ranges from days to weeks . The infection is in the labyrinth, a structure in your inner ear that controls balance and hearing. A viral illness, such as a cold or flu, often causes this infection. A bacterial ear infection is also sometimes the cause . Typically , no treatment is required for labyrithitis . However, if suppurative labyrinthitis is suspected, the patient should be referred to the emergency department for drainage of otitis media .

63. Meniere’s disease Ménière’s disease is an uncommon cause of vertigo. It is thought to be caused by increased fluid in the endolymph part of the cochlea, which eventually affects the semicircular canals.  In most patients, the aetiology is unknown.Ménière’s disease is commonly seen in women, and the incidence increases in men and women after the age of 60 years. Ménière’s disease classically presents with episodes of vertigo lasting longer than 20 minutes, tinnitus, sensorineural hearing loss and aural fullness . Eventually, hearing loss becomes permanent . Pure tone audiometry is the most useful test to assess sensorineural hearing loss. There is no known cure for Ménière’s disease and treatment is primarily symptomatic.   Betahistine is the current mainstay of treatment. Surgical treatment options exist; however, most patients are adequately managed with medical treatment.

64. Vestibular neuronitis VN is caused by inflammation of the vestibular nerve . This inflammation precedes a viral URTI or herpes zoster infection and is caused by immune-mediated sequelae following the viral illness. It is commonly seen in middle-aged adults of both sexes. The main characteristic of VN is an acute onset of vertigo without hearing loss or tinnitus. Similarly to BPPV, symptoms of vertigo are aggravated by a change in the position of the head . Loss of balance is more prominent in VN, compared with other causes of vertigo, and patients may commonly present with falls. Initially, the vertigo is severe , lasts for two to three days and is followed by gradual recovery , which may take two to six weeks.   Patients can be reassured that symptoms will improve with time.

65. Differential diagnosis Onset and duration of each attack of vertigo Provoking factors Special features Physical exam findings Labyrinthitis Few seconds to minutes Change in the head position Tinnitus Hearing loss present Vestibular neuronitis Seconds to minutes Recent upper respiratory tract infection Imbalance, while nystagmus is horizontal or rotational, the direction of the fast component is away from the side of the lesion Absence of hearing loss Benign paroxysmal positional vertigo Seconds Change in the head position Positional Positive Dix−Hallpike Ménière’s disease Hours Spontaneous Hearing loss and tinnitus Hearing assessment for sensorineural hearing loss

66. Investigations Laboratory Evaluation Laboratory tests such as electrolytes, glucose, blood counts, and thyroid function tests identify the etiology of vertigo in fewer than 1 percent of patients with dizziness. They may be appropriate when patients with vertigo exhibit signs or symptoms that suggest the presence of other causative conditions . Audiometry helps establish the diagnosis of Ménière’s disease.

67. Neuroimaging studies Physicians should consider neuroimaging studies in patients with vertigo who have neurologic signs and symptoms , risk factors for cerebrovascular disease, or progressive unilateral  In general, magnetic resonance imaging is more appropriate than computed tomography for diagnosing vertigo because of its superiority in visualizing the posterior fossa, where most central nervous system disease that causes vertigo is found. Magnetic resonance or conventional angiography of the posterior fossa vasculature may be useful in diagnosing vascular causes of vertigo such as vertebrobasilar insufficiency, thrombosis of the labyrinthine artery, anterior or posterior inferior cerebellar artery insufficiency, and subclavian steal syndrome. Neuroimaging studies can be used to rule out extensive bacterial infections, neoplasms, or developmental abnormalities if other symptoms suggest one of those diagnoses.

68. Treatment Treatment is specific to the cause of vertigo . Treatment is tailored to the specific causes of vertigo. Antiemetic medications such as betahistine are used for symptomatic management of acute vertigo. These medications should not be used long term. Patients should be warned about the side effects of drowsiness, dry mouth and blurred vision . Lifestyle changes including salt restriction and avoiding alcohol and coffee are recommended.  Assessment and management of the patient’s risk of falls is important in vertigo. Referral to an experienced physiotherapist for vestibular rehabilitation can help prevent recurrences.  Exercises prescribed by physiotherapists involve moving the eye balls up and down and sideways in a supine or sitting position. Balance stabilisation exercises help to regain normal activities faster. Patients should be referred for specialist review if they have symptoms of continuous vertigo, progressive hearing loss, severe ongoing headache, cerebellar signs or if the diagnosis is not clear .