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The treatment of acute vertigo

The treatment of acute vertigo. Cesarani A, Alpini D, Monti B, Raponi G Neurol Sci 2004;24:S26-30. 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

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The treatment of acute vertigo

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  1. The treatment of acute vertigo Cesarani A, Alpini D, Monti B, Raponi G Neurol Sci 2004;24:S26-30.

  2. 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

  3. Two main group of acute vertigo • Spontaneous vertigo • Provoked vertigo ( paroxysmal positional vertigo, PPV, BPPV )

  4. 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

  5. Stage 1: irritation • Spontaneous nystagmus beats towards the affected side • Normal caloric reaction ( cold waterbeat 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

  6. 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

  7. 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

  8. Stage 1: irritation • Stage 2: sudden loss of paralysis of the system • Stage 3: central compensation • Stage 4: recovery • Nystagmus towards the affected side

  9. Early phase • 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 Stage1&2

  10. 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)

  11. Pharmacotherapy

  12. Physical therapy • Vestibular electrical stimulation ( VES) • Exercise

  13. 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: p’t 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

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

  15. Exercise in sitting(1) • Performed during VES and wearing visual prisms (saccade)

  16. Exercise in sitting(2)

  17. 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.

  18. 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 • P’t supine, rolling the head from side to side • Pure horizontal geotropic and ageotropic nystagmus

  19. Treatment for PPV • Semont maneuver • Epley maneuver • Personal maneuver for PPV elicited by Dix-Hallpike positioning ( Epley modified) • Lempert maneuver horizontal semicircular lithiasis post. Semicircular canal lithiasis 80~90%effective

  20. Semont maneuver Right ear lat canal PPV • Head turn towards left side(SS) • Lying on R side, head is rotated upward 105°, 3mins • Lying on L side, head is rotated downward 195°, 3 mins • Slowly sit-up 1 & 4 頭朝左轉 3 眼睛朝下看 2 眼睛朝上看 http://www.neurology.org/cgi/content/full/63/1/150/DC1 (video 1)

  21. 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)

  22. Modified Epley Left ear BPPV 30 sec 30 sec

  23. Lempert maneuver Right ear PPV 30~60 sec

  24. Thank you for your attention

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