The Study Of The Spectrum Of Vertigo With Special Reference To Vertigo Of Vascular Origin

Shamas IU, Waqay F, Islam MU, Pampori R Abstract Objectives: To outline the spectrum of vertigo, to elaborate the significance of vascular causes of vertigo, to advocate use of MRI / MRA of carotid artery and vetebrobasilar arterial system in patients with isolated or syndromic vertigo especially when one or more risk factors for a cerebrovascular accident are present. Study design: Prospective study(2009-2011). Results: 91 patients who preened with vertigo were prospectively studied. BPPV, Meniere’s disease and vestibular neuritis comprised about 60% of patients. Posterior circulation syndrome and vertebrobasilar insufficiency was strongly suspected in 13 patients (14.3%). Compression of 8 th nerve and cerebellar vermis were documented to be the cause of vertigo in 7 patients (7.7%), cervical vertigo was seen in 6(6.6%) patients. 4 patients (4.4%) had vertigo as a manifestation of complicated CSOM. 3 (3.3%) patients had metabolic vascular syndrome out of which one patient died of stroke about 6 months after his presentation as recurrent episodic vertigo. No diagnosis could be made in 3 patients. Conclusion:A detailed history should be obtained and an elaborate vestibular and neuro-otologic examination done in a patient of vertigo. A diagnosis can be reached in more than 90% of patients. Peripheral vertigo is more common that central vertigo with BPPV, meniere’s disease and acute vestibular neuritis accounting for more than 60% of all cases of vertigo. Vascular causes form a significant group of vertigo patients. Vertigo especially recurrent and syndromic with 1 or more risk factors should not be overlooked and should be regarded a precursor of a future stroke. Patients of vertigo with vascular risk factors like age (elderly), hypertension, smoking, diabetes mellitus, hyperlipidemia and cardiac disease should be evaluated for vertebrobasilar insufficiency by specific investigations like MRI brain, MRA carotids and vertebrobasilar arteries, Doppler USG and risk factors for vascular disease modified by drugs (hypolipidemic, antihypertensive, aspirin) and behavioural changes. Abnormal vessel loops can compress VIII nerve and cause vertigo. These can be reliably diagnosed by MRA. Vertigo can be caused in patients with cervical spondylosis especially in previously diseased vessels (due to atherosclerosis, vasculitis) which get easily compressed by cervical osteophytes.


Introduction
The overwhelming vertigo, the awful sickness and the turbulent eye movements all enhanced by slightest movements of the head, combine to form a picture of helpless misery that has few parallels in the whole field of injury and disease.Vertigo still remains less understood entity and still puzzles many clinicians.Definition: Vertigo is the illusion of movement of the body or the environment.Vertigo is defined by the new oxford dictionary of English "as a sensation of whirling and loss of balance, associated particularly with looking down from a great height, or caused by disease affecting the inner ear or the vestibular nerve; giddiness."Patients, therefore, also use the term vertigo, gid-diness and dizziness interchangably and differentiation between these words has become somewhat blurred.
The American Academy of Otolaryngology and Head & Neck Surgery Committee on hearing and equilibrium guidelines define vertigo as 'the sensation of motion when no motion is occurring relative to the earth's gravity' in contrast to motion intolerance which is a feeling of disequilibrium, spatial disorientation or malaise during active or passive movement 1 .Problem Statement: Vertigo is a common symptom especially in the elderly.By the age of 65, one third of population has suffered symptoms of imbalance and in the community one in five of the adult population have suffered such symptoms with 30% of Corresponds to: Dr. Irfan ul Shamas, Registrar, ENT, GMC, Srinagar, Kashmir.E-mail: drir-fan007@gmail.comBangladesh Journal of Medical Science Vol. 12 No. 02 April'13 these symptoms for more than four years.Of all, benign paroxysmal positional vertigo is thought to be the most common cause and forms about 25% of all vertigo patients who present at health institutions 2 .Vertigo of vascular origin appears to be more common in the elderly above 50 years of age.Despite the obvious public health significance, these patients typically have great difficulty accessing good quality healthcare and are generally perceived by otolaryngologists to represent one of the most frustrating and frustrated group of patients.However, a diagnosis can be made in the majority of cases from a focused history and examination with selective adjunctive use of MRI, MRA etc. Pathophysiology of Vertigo: Human beings have a complex mechanism for maintaining balance; including visual, proprioceptive and vestibular inputs, which are integrated within the CNS and modulated by the cerebellum, the extrapyramidal system, the reticular formation and the cortex.This integrated modulated activity provides the means of controlling oculomotor function, posture, gait and motor skills in addition to allowing the perception of head and body position in space.A mismatch of information from any of these organs causes vertigo 3 .

Causes:
The disorders giving rise to vertigo can be broadly categorized into two main groups: Peripheral Vertigo: Wherein the cause lies in the internal ear or eighth nerve i.e. upto 1 st order neurons.Central Vertigo: Wherein the cause lies in the CNS after the entrance of vestibular nerve in the brainstem and involves vestibulo-ocular, vestibulospinal and other CNS pathways.(14.2%), cervical vertigo (6.6%), metabolic vascular syndrome (3.3%), dolichoectasia of basilar artery (1%).One of the patients grouped under metabolic vascular syndrome died of stroke about 6 months after his initial presentation as vertigo.

SUMMARY AND CONCLUSION:
Based on the observations of this study and the review of the literature we conclude as under: A detailed history should be obtained and an elaborate vestibular and neuro-otologic examination done in a patient of vertigo.A diagnosis can be reached at in more than 90% of the patients.Peripheral vertigo is more common that central vertigo with BPPV, meniere's disease and acute vestibular neuritis alone accounting for more than 60% of all cases of vertigo.Vascular causes form a significant group of vertigo patients .Vertigo especially recurrent and syndromic with 1 or more vascular risk factors should not be overlooked and should be regarded a precursor of a future stroke.Patients of vertigo with vascular risk factors like age (elderly), hypertension, smoking, diabetes mellitus, hyperlipidemia and cardiac disease should be evaluated for vertebrobasilar insufficiency by specific investigations like MRI brain, MRA carotids and vertebrobasilar arteries, Doppler USG and risk factors for vascular disease modified by drugs (hypolipidemic drugs, antihypertensives, aspirin) and behavioural changes and dietary modifications.These patients are actually at risk for a future stroke.Abnormal vessel loops can compress VIII nerve and cause vertigo.These can be reliably diagnosed by MRI/MRA.Vertigo can be caused in patients with cervical spondylosis especially in previously diseased vessels (due to atherosclerosis, vasculitis) which can get easily compressed by cervical osteophytes.
Vertigo can be classified in different ways, but the most common classification is the clinical topographic classification described above that divides it into central and peripheral vertigo, in an attempt to distinguish between neurological and otological problems.Although we are aware that there are Above table and graph shows that about 77% of patients were in the age group of 30-60 years with only 1 patient having vertigo in the 0-20 age group in this study.

Table - IV: Vertigo parameters in the studied subjects
Table shows isolated vertigo to be fairly common in this study present in about 32% of the patients.Most common associated symptoms in this study were hearing loss (40%), vomiting (35%) and tinnitus (30%)

Table shows Dix
Hallpike's test positive in 25% of patients and cerebellar signs present in about 9% of patients.Therefore a complete examination is necessary in vertigo patients to reach at a diagnosis.

Table - VI: Caloric Testing(n=19) Testing No. of Patients Percentage
Table shows hypoactive labyrinth in 6 patients (31%) out of 19 patients tested in this study.

Table - VII: CT Findings in the Studied Subjects (n=23) CT Findings No. of Patients
Table shows abnormal CT findings in 7 patients out of 23 patients in which CT was ordered (30.4%) with one patient having a frank infarct not suspected on initial history and examination.Other patient was having widening of IAC and was diagnosed as vestibular schwannoma on MRI.

Table - VIII: Doppler Carotids and VBA(n=10)
Table shows atheromatous plaques and intimal thickening in 4 out of 10 patients of vertigo in whom Doppler study was ordered in this study.Table shows 7 patients having vertigo due to ischaemia and compression of 8 th nerve and its central connections diagnosed on MRI in this study.Table shows BPPV to be the most common cause of vertigo.Vascular causes appear to be etiology of vertigo in 25% of patients in this study including posterior circulation syndrome and VBI