Vertigo is a self-perception error of one’s own balance and spatial phase perception, and perception of motion hallucinations of oneself or external objects, such as rotation, elevation or tilt. Vertigo is one of the common clinical symptoms rather than an independent disease. Vertigo involves the vestibular nervous system, the visual system and the proprioceptive system in a multisensory syndrome, and the vestibular nervous system plays a dominant role among the three. Vestibular dysfunction manifests as follows.
1. Damage to the vestibular nerve on one side causes imbalance of afferent impulses on both sides, producing vertigo sensation in the cerebral cortex.
The vestibular eye reflex is impaired, and the vestibular nerve nucleus is connected to the motor nerve, the nucleus pulposus and the abducens nucleus through the medial longitudinal bundle, and nystagmus occurs when this path is damaged.
3.The vestibular nerve nucleus connects with the vestibular cells through the vestibulospinal tract, which constitutes the vestibulospinal reflex pathway. The vestibulospinal reflex is abnormal and produces balance disorders and ataxia.
4. Vagus nerve excitation appears as nausea and vomiting.
Classification
It is customary to classify systemic vertigo (peripheral and central vertigo) and non-systemic vertigo caused by systemic diseases according to the location of the lesion.
Systemic vertigo : Central: TIA of the posterior circulatory system, infarction, tumor of the fourth ventricle or cysticercosis, etc.
Peripheral: vestibular system diseases: vestibular neuronitis Meniere’s disease benign positional vertigo, etc.
Non-systemic vertigo: It is caused by systemic diseases other than the vestibular system.
Classification
Central vertigo refers to vertigo caused by intracranial segment of vestibular nerve, vestibular nucleus, supranuclear fibers, medial longitudinal tract, cerebellum and cerebral cortex lesions. Vertigo can be mild but long-lasting and is commonly seen in diseases such as posterior circulation ischemia, brainstem infarction, cerebellar infarction or hemorrhage, cervical spondylosis, etc. It is also seen in cerebellar tumors, auditory neuroma, fourth ventricular brain tumor, temporal lobe tumor or epilepsy.
Clinical manifestations
1, vertigo: mild degree, long duration, (weeks or years), rotation of vision or sense of movement to one side.
2. Nystagmus: large amplitude, variable form, and inconsistent direction of nystagmus.
3.Balance disturbance: inconsistent tilting direction, not related to head position change.
4.Much of it is not accompanied by tinnitus, hearing loss and autonomic symptoms.
5.Sometimes it is accompanied by cranial nerve damage, limb paralysis and other central nervous system symptoms and signs.
Common diseases of central vertigo
1.Posterior circulation ischemia refers to: posterior circulation transient ischemic attack (TIA) and cerebral infarction, (20% of ischemic cerebrovascular disease is caused by posterior circulation ischemia.)
Main causes.
① atherosclerosis of the posterior circulation system causing stenosis.
②Embolysis (emboli mainly originate from the heart, aorta and vertebrobasilar artery).
③Subclavian artery steal syndrome: Reverse shunt of vertebral artery blood to the subclavian artery due to occlusion of the subclavian artery before the beginning of the vertebral artery.
Presentation: Recurrent TIA and stroke present as a combination of signs and symptoms associated with the site of ischemia, rarely causing a single symptom. The main features are vertigo, coarse nystagmus, balance disturbance with or without tinnitus and hearing loss. Bilateral or unilateral motor and sensory deficits, vertigo, ataxic gait, poor distance discrimination, diplopia, swallowing and dysarthria or bilateral isotropic hemianopia, and other cranial nerve symptoms are present. Only less than 1% of patients show a single symptom or sign.
2. Brainstem infarction mainly manifests as vertigo, vomiting, tetraplegia, ataxia, coma, and hyperthermia.
Dorsolateral medullary syndrome is the most common type of brainstem infarction, which is a syndrome of occlusion of the posterior inferior cerebellar artery or vertebral artery.
It manifests as vertigo, vomiting, nystagmus Crossed sensory disturbance (peripheral facial palsy on the focal side, contralateral limb palsy) Horner’s sign on the focal side Choking on water, dysphagia, hoarseness Cerebellar ataxia on the focal side
Cerebellar infarction or hemorrhage
Clinical manifestations: vertigo, vomiting, nystagmus, ataxia, unsteadiness and reduced muscle tone. Larger infarcts may be associated with brain herniation leading to coma, respiratory and circulatory failure and death.
Peripheral (true) vertigo refers to vertigo caused by lesions of the vestibular receptors and the intracranial segment of the vestibular nerve (not out of the internal auditory tract). The vertigo is heavy, short-lasting, and may be accompanied by fluctuating tinnitus, deafness, and vegetative symptoms such as nausea and vomiting and decreased blood pressure. There is no impairment of consciousness and other symptoms of damage to the cranial nerves and other systems. It is common in Meniere’s disease, benign episodic positional vertigo, vestibular neuronitis, labyrinthitis, otitis media, mastoiditis, etc.
Common diseases of peripheral vertigo
1. Ménière’s disease is an idiopathic inner ear disease with the basic pathological change of membrane vagus fluid accumulation, which manifests clinically as recurrent rotational vertigo, sensorineural deafness, tinnitus and ear fullness, and no vertigo attacks in intervals. It is mostly seen in young adults and usually develops in one ear.
Diagnosis is based on.
(1) Episodes of severe rotational vertigo 2 or more times, each lasting 20 minutes to several hours, or up to several days.
(2) Fluctuating hearing loss, mostly low-frequency hearing loss in the early stage, with progression of cold sweat, blood pressure drop and other autonomic disturbances and balance disorders. No loss of consciousness. Hearing loss gradually worsens.
(3) With tinnitus and/or a sense of ear fullness. Often accompanied by nausea, vomiting, pallor, and sweating.
(4) Vestibular function examination: spontaneous nystagmus and/or abnormal vestibular function may be present.
(5) Exclude vertigo caused by other diseases, such as benign paroxysmal positional vertigo, vaginitis, vestibular neuronitis, drug-induced vertigo, sudden deafness, posterior circulation ischemia and intracranial occupying lesions.
2, benign episodic positional vertigo This disease is one of the most common diseases of peripheral vertigo, which is a vestibular semicircular canal disease with symptoms induced by postural changes.
Clinical manifestations.
The onset is sudden and the patient experiences intense rotational vertigo with nystagmus, nausea and vomiting during head position changes. Symptoms occur when sitting down, or when moving from a lying to a sitting position, or when turning over in bed, and patients often notice vertigo when turning sideways to a particular head position. The patient often wakes up during sleep due to vertigo attacks. Consciousness is clear and lasts less than 1 minute. It is a self-limiting disease with good healing.
3. More than half of the patients with vestibular neuritis have a history of respiratory tract infection. It is associated with viral infection and may also be a manifestation of polycystic cranial neuritis without cochlear damage, and may heal spontaneously.
Clinical manifestations.
(1) History of anterograde supratentorial sensation.
(2) Sudden onset of severe rotational vertigo, which is aggravated by head movement, with significant balance disturbance, and may be accompanied by nausea and vomiting.
(3) Early onset of horizontal or horizontal rotational nystagmus, mostly pointing to the healthy side.
(4) There is no tinnitus, hearing impairment or other cranial nerve damage.
(5) After the acute attack, the vertigo and balance disorder will gradually decrease, but the symptoms should last for several weeks or months or more.
(6) Vestibular function examination: mild paralysis or palsy of the affected hemiplegia, and some vestibular functions may return to normal.
Non-systemic vertigo manifests as dizziness and unsteadiness, usually without the sense of rotation or swaying in the external environment or oneself, rarely accompanied by nausea and vomiting, also known as pseudovertigo.
It is caused by systemic diseases other than vestibular system.
1.Ocular diseases.
2. Anemia or blood disorders: vertigo is caused by disorders of hematopoietic and coagulation mechanisms.
3.Cardiogenic vertigo: accompanied by serious cardiovascular diseases.
4.Low blood pressure and hypertensive vertigo: vertigo is related to blood pressure fluctuation.
5.Endocrine metabolic diseases.
6.Infection, poisoning, neurological dysfunction.
7.Hereditary vertigo: it is accompanied by certain genetic diseases such as hereditary nephropathy-deafness syndrome, vestibulocerebellar ataxia, etc.
8, Hypoglycemic vertigo.
9.Nephrotic vertigo.
10.Gestational vertigo.
Migrainous vertigo Vertigo in migraine can be accompanied by headache, sometimes earlier than headache, sometimes later than headache, or temporarily unrelated to headache.
The vestibular symptoms of migrainous vertigo mainly include.
(1) Spontaneous vertigo: the illusion of one’s own motion or the illusion that the visual field is rotating or floating.
(2) Positional vertigo: occurs after a change in head position.
(3) Visually induced vertigo: induced by complex or large moving visual stimuli.
④Head movement induced vertigo: Occurs when the head is moving.
⑤ Head activity induced dizziness with nausea.
Diagnostic criteria for vestibular migraine.
Epileptic vertigo: It is a transient, sudden and recurrent illusion of rotation, drifting, tilting and feeling of falling in space of oneself or surrounding scenery caused by abnormal discharge of cortical neurons in the vestibular system, often without aura before the attack, and the attack is also manifested as sudden vertigo, which usually recovers quickly and lasts for several seconds or tens of seconds. The cause is related to damage to the insula or parietal lobe. The onset of vertigo is position-independent, sudden, and may be accompanied by nausea and vomiting, usually without nystagmus. Patients may wake up during sleep due to vertigo attacks, and may fall down when having an attack in standing position. EEG examination is good for diagnosis.
Cervical vertigo mostly occurs during cervical spine movement, accompanied by neck, shoulder and back pain, or restricted neck movement, occipital headache, nausea and vomiting, palpitations, tinnitus and weakness. On examination, we can see pressure pain in the corresponding spinous process, interspinous and transverse foramina of the neck, distortion of the spinous process, and positive rotational neck test. Many people equate cervical vertigo with inadequate blood supply to the vertebral artery, but it is now believed to be only one of the important causes, which is associated with multiple factors such as sympathetic nerve stimulation, vascular lesions and hemodynamic abnormalities, cervical proprioceptive disorders, and humoral factors.
Vertigo and affective disorders Patients with vertigo are often accompanied by depression or (and) anxiety. Any vertigo attack accompanied by symptoms such as inattention or brain blankness, sleep disturbance, fatigue or weakness, increased alertness, premonition of something bad happening, sense of hopelessness, low self-esteem and sense of worthlessness should be considered as possible affective disorders, which are mutually causal in clinical practice and therefore require comprehensive treatment.
Myth.
Dizziness/vertigo = posterior circulation ischemia
A significant number of patients with dizziness/vertigo have undergone TCD and often have been suffering from dizziness/vertigo for a long time. With such a diagnostic report, patients are not allowed to believe that they have cerebral insufficiency. The main clinical manifestation of posterior circulation ischemia is accompanied by other cerebellar/brainstem signs and symptoms besides dizziness/vertigo.
Dizziness/vertigo = cervical spondylosis
A significant number of dizziness/vertigo patients, especially in the elderly, have had cervical-X-rays taken. Diagnoses that often appear on cervical-X-ray reports include: straightening of the cervical curvature, narrowing of the vertebral space, and osteophytes. These patients themselves ask, “Is my lack of blood supply to the brain caused by cervical spondylosis?” Studies have shown that mechanical compression of the cervical spine is not a major cause of dizziness or vertigo, less than 5%.
Dizziness/vertigo = cavernous infarction
It is not uncommon to see a patient with dizziness/vertigo whose first words are “I’m dizzy, doctor,” and whose second words may be “I have a cerebral infarction” or “I have a cavernous infarction. “.
The second sentence may be “I have a cerebral infarction” or “I have a cavernous infarction”. The patient’s meaning is clear: my dizziness/vertigo is caused by cavernous infarction in the brain, doctor, see how to treat my dizziness/vertigo by treating my cavernous infarction.