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Curiculum vitae

Dr. RB. Wirawan Sp.S(K)

Lulus dokter FK Undip 1966


Lulus Spesialis Saraf FK Unair 1975
Dosen Luar Biasa FK Undip
Ketua Kelompok Studi Nyeri PERDOSSI Semarang
Wakil ketua Ikatan Rematologi Indonesia Semarang
Anggota Kelompok Studi Nyeri Pinggang Indonesia
Anggota International Association for Study of Pain
VERTIGO
Dr. RB Wirawan, Sp.S(K)
PHILOSOPHY OF LIFE
(KONG HU CU)

LEARNING
SHARING
TEACHING
WHAT IS VERTIGO?

A SENSATION OF MOVEMENT
CHARACTERISED BY FEELING
OF ROTATION OR SPINNING
VERTIGO PREVALENCE

VERTIGO IS VERY COMMON


IN POPULATION-BASED STUDIES: 4-7%
IN PEOPLE AGED OVER 75 YEARS:
- 40% OF WOMEN
- 30% OF MEN
Maintaining balance is dependent
on input from a number of sources
Eye Skin pressure receptors

Inner ear
Muscle and joint
(vestibular system)
sensory receptors
Central Nervous system

Controls eye Postural control


movements via muscles

Balance

Goebel JA. Otolaryngol Clin North Am 2000;33:48393.


Shepard NT, Solomon D. Otolaryngol Clin North Am 2000;33:45569
The vestibular system is the dominant sensory
input guiding balance

Utricle Otolith
Semicircular Saccule organs
canals

Vestibular nerve

Cochlea
Ampullae

Sensory hair cells within the inner ear provide information


on the position and movement of the head
Goebel JA. Otolaryngol Clin North Am 2000;33:48393.
Vertigo is one of four types of dizziness

Dizziness

Vertigo Presyncope Disequilibrium Other


subtypes
An illusion of A feeling of A sense of Swimming or
movement, faintness or unsteadiness in the floating
usually loss of lower body sensations
rotation consciousness Feelings in the head Feelings of
are unaffected dissociation
Relieved when Difficult to
sitting down describe

Drachman DA, Hart CW. Neurology 1972;22:3234. Sloane PD et al. Ann Intern Med 2001;134:82332.
Vertigo can be of central or
peripheral origin
Central
Involving structures in
the central nervous
system
(e.g., cerebrum,
cerebellum, brainstem)
Peripheral
Involving structures not
part of the central
nervous system, most
frequently the inner ear
VERTIGO
PERIPHERAL vs CENTRAL
Symptom Likely aetiology
Peripheral Central
Vertigo episodes Mild/modete Chronic and
unremitting
Symptom onset Sudden Gradual
Imbalance Mild/modete Severe
Nausea, vomiting Severe Varying
Auditory symptoms Common Rare
Neurological symptoms Rare Common
Changes in mental status/ Infrequent Sometimes
consciousness
Compensation/resolution Rapid Slow
Baloh RW. Otolaryngol Head Neck Surg 1998;119:559. Puri V, Jones E. J Ky Med Assoc 2001;99:31621.
PRACTICAL POINT

PERIPHERAL VERTIGO:
SUDDEN ONSET
WITH NAUSEA AND VOMITING
NO NEUROLOGICAL SYMPTOM
NO CHANGE IN COUNCIOUSNESS

CENTRAL VERTIGO:
GRADUAL ONSET
PERSISTING DURATION
SEVERE IMBALANCE
NEUROLOGICAL SYMPTOM (+)
Vertigo of Peripheral origin: causes
Condition Details
Benign paroxysmal Brief, position-provoked vertigo episodes caused by
positional vertigo abnormal presence of particles in semicircular canal
(BPPV)
Menieres disease An excess of endolymph, causing distension of
endolymphatic system
Decreasing frequency

Vestibular neuronitis Vestibular nerve inflammation, most likely due to virus


Acute labyrinthitis Labyrinth inflammation due to viral or bacterial infection
Labyrinthine infarct Compromises blood flow to the labyrinthine
Labyrinthine Damage to the labyrinthine after head trauma
concussion
Perilymph fistula Typically caused by labyrinth membrane damage
resulting in perilymph leakage into the middle ear
Autoimmune inner ear Inappropriate immunological response that attacks inner
disease ear cells

Baloh RW. Lancet 1998;352:18416. Mukherjee A et al. JAPI 2003;51:1095-101. Parnes LS et al. CMAJ
2003;169:681 93. Puri V, Jones E. J Ky Med Assoc 2001;99:31621. Salvinelli F et al. Clin Ter 2003;154:3418.
Vertigo of Central origin: causes

Condition Details
Migraine Vertigo may precede migraines or occur concurrently

Vascular disease Ischaemia or haemorrhage in vertebrobasilar system


Decreasing frequency

can affect brainstem or cerebellum function


Multiple sclerosis Demylination disrupts nerve impulses which can
result in vertigo
Vestibular Vertigo resulting from focal epileptic discharges in
epilepsy the temporal or parietal association cortex
Cerebellopontine Benign tumours in the internal auditory meatus
tumours

Baloh RW. Lancet 1998;352:18416. Mukherjee A et al. JAPI 2003;51:1095-101. Salvinelli F et al. Clin Ter 2003;154:
3418. Solomon D. Otolaryngol Clin North Am 2000;33:579601. Strupp M, Arbusow V, Curr Opin Neurol 2001;14:1120.
IMPACT OF VERTIGO EPISODE / CRISIS

Vertigo episodes are often accompanied by:


nause
anxiety
vomiting
sweating
imbalance
nystagmus

Baloh RW. Lancet 1998;352:18416. Mukherjee A et al. JAPI 2003;51:1095101.


Salvinelli F, Firrisi L, Casale M, et al. Clin Ter 2003;154:3418.
IMPACT AFTER VERTIGO EPISODES
SYMPTOMS BETWEEN VERTIGO EPISODE
Anxiety
Instability
Headache
Depression
General malaise
Fear over recurrence of episodes

CONTINUOUS BURDEN

NEGATIVE EFFECT ON QOL!


Fielder H et al. Clin Otolaryngol 1996;21:1246. Hgnebo C et al. Scand Audiol 1997;26:6976. Lopez-Escamez JA,
Lopez-Nevot A. Acta Otorrinolaringol Esp 2000;51:37782. Mendel B et al. Clin Otolaryngol Allied Sci 1999;24:28693.
Monzani D et al. J Psychosom Res 2001;50:31923. Salvinelli F et al. Clin Ter 2003;154:3418.
Etiologythe
Identifying Diagnosis
cause:
1. Acute spontaneous vertigo
Investigate history: Viral/systemic illness? Stroke or TIA? Otitis? Head trauma? Syphilis?

Moderate imbalance Moderate imbalance Severe imbalance


Spontaneous uni- Spontaneous uni- Direction changing
directional nystagmus directional nystagmus nystagmus
Asymmetric VOR Asymmetric VOR Focal neurological
Unilateral hearing loss Normal hearing findings

Treat symptoms and


Blood screen observe for 48 hours Perform MRI

Viral neurolabyrinthitis Better No change


Otomastoiditis Cerebellar infarct or
Autoimmmune inner ear haemorrhage
disease Brain stem infarct
Vestibular Multiple sclerosis
Labyrinthine infarct or neuritis
concussion

Baloh RW. Otolaryngol Head Neck Surg 1998;119:559. VOR, vestibular-ocular reflex. MRI, Magnetic Resonance Imaging.
2. Recurrent episodes sensitive to head position
Investigate history: Prior ear infection? Head trauma?

Sustained pure vertical Fatigable torsional


positioning nystagmus positioning nystagmus
or associated
neurological findings

Perform MRI

Cerebellar tumour Benign paroxysmal


Multiple sclerosis positional vertigo
Cerebellar atrophy

Baloh RW. Otolaryngol Head Neck Surg 1998;119:559. MRI, Magnetic Resonance Imaging.
3. Recurrent episodes insensitive to head position
Investigate history: Age? Attack duration? Hearing loss?
Neurological symptoms? Migraine? Autoimmune illness?

Focal neurological findings Unilateral hearing loss No other defining symptoms

Perform MRI Audiogram; ENG

Asymmetric hearing Normal hearing and Normal hearing


and calorics asymmetric calorics and calorics

Blood screen

Vertebrobasilar Menieres Menieres Vertebrobasilar


ischemia Autoimmune Migraine ischemia
Multiple sclerosis disease Migraine
Syphilis

Baloh RW. Otolaryngol Head Neck Surg 1998;119:559. MRI, Magnetic Resonance Imaging. ENG, Electronystagmogram.
CURRENT MANAGEMENT OPTIONS

TREATMENT MODALITIES
1.Treat the underlying cause
Pharmacotherapy
Particle repositioning procedure (in BPPV)
Surgery
2. Symptomatic
Pharmacotherapy
3. Rehabilitative
Promote long-lasting neural reorganisation
Vestibular rehabilitation exercises

THERAPEUTIC MODALITIY OPTION


Depends on the type and cause of vertigo

Baloh RW. Lancet 1998;352:18416. Mukherjee A et al. JAPI 2003;51:1095-101.


1. Treatment depends on type and cause
of vertigo
Vertigo type Treatment
PERIPHERAL CAUSE
BPPV Canalith repositioning manoeuvre (Brandt-Daroff)
Labyrinthine concussion Vestibular rehabilitation

Menieres disease Low-salt diet, diuretic, surgery, transtympanic gentamicin

Labyrinthitis Antibiotics, removal of infected tissue, vestibular rehabilitation

Perilymph fistula Bed rest, avoidance of straining


Vestibular neuritis Brief course of high-dose steroids, vestibular rehabilitation

CENTRAL CAUSE
Migraine Beta-blockers, calcium channel blockers, tricyclic amines

Vascular disease Control of vascular risk factors, e.g., antiplatelet agents

Cerebellopontine tumours Surgery


Treating the cause: surgery
Clinical picture
Patient presents with

Vertigo-inducing tumour Recurrent vertigo due to unilateral


(e.g., cerebellopontine vestibular damage unresponsive to
tumour) medical therapy
Surgery

Tumour removal Ablative Non-Ablative

Menieres disease or Menieres disease:


peripheral vestibulopathy: Endolymphatic sac shunt or
Labyrinthectomy decompression
Vestibular nerve section BPPV:
Posterior canal occlusion

Goebel JA. Otolaryngol Clin North Am 2000;33:48393. Salvinelli F et al. Clin Ter 2003;154:3418.
2. SYMPTOMATIC THERAPY
ANTIVERTIGO
I. Vestibular Suppressant
1. Ca antagonist : Flunarizin
2. Vasodilator : Betahistine
3. Tranquilizer : diazepam, haloperidol, sulpiride
4. Antihistamin : Difenhidramine, meclizine.
5. CNS stimulant: ephedrin, amphetamin

II. Antiemetic
1. Anticholinergic : atropine, scopolamine
2. Phenotiazine : Prochlorperazine, metoclopramide.

Side effects: sedation, extrapyramidal.


3. There are several types of vestibular
rehabilitation exercises
Vestibular rehabilitation exercises

Head and neck Visual-vestibular Postural stability


interaction
Performed lying, Promotes visual- Improves static and
sitting or standing vestibular interaction dynamic posture
Vertigo-inducing Involves ocular and Manipulates visual,
movements of head hand-eye co-ordination somatosensory and
and neck in different exercises vestibular cues
planes Uses the vestibulo- Involves trunk rotation,
Uses cervical-ocular ocular reflex head rotations, and
reflex gait exercises

Rehabilitation exercises differ in their target

Konnur MK. J Postgrad Med 2000;46:2223.


An alternative treatment for VERTIGO:

NOOTROPIL
Balance requires information of similar
intensity from both vestibular systems
Head movement

Activation of cells Activation of cells


in left in right vestibular
vestibular system system

Central nuclei

10 10

Normally, the input from left and right vestibular


system is of similar intensity (e.g. of size 10)
Central vertigo results from a
dysfunction in central processing
Central nuclei

10 10

Input from left and right vestibular system remains of similar


intensity, but central processing is impaired (e.g. of size 10)

Central vertigo requires central treatment


Peripheral vertigo results from a dysfunction
in vestibular system functioning

Central nuclei

5 10

In some cases, peripheral vertigo can be cured


In other cases, only symptomatic treatment is available
If treatment is unsuccessful, vertigo may improve
slowly as compensatory mechanisms are established
Vestibular suppressants suppress
vestibular function in both ears
Central nuclei

5 10
1 2

Vestibular suppressants modify peripheral function


bilaterally
Nootropil offers an interesting
alternative to existing treatments
Central nuclei

5 10

Piracetams mechanism of action is thought to facilitate


compensatory processes in the central system thereby
providing sustained relief from vertigo

Nootropil monograph 2004.


Restored membrane fluidity could account
for Nootropils efficacy in vertigo
Neuronal effects Vascular effects
Restored neurotransmission Enhanced erythrocyte
Enhanced neuroplasticity deformability
Improved metabolism Decreased adhesion of
erythrocytes to endothelial wall
Facilitation of interhemispheric
information transfer Prevention of vasospasm
Normalised platelet
hyperaggregability

Improved neuronal function Improved microcirculation

Facilitates vestibular compensation and adaptation

Adapted from Winblad B. CNS Drug Rev 2005; 11(2):169-82.


CLINICAL TRIALS
NOOTROPIL IN
1. Peripheral Vertigo
2. Central Vertigo
3. Between vertigo episodes
4. Post-concussion
5. Chronic vertigo
6. Improving Quality of Life
7. Improving social and professional function
Nootropil eliminates vestibular symptoms in more
patients with peripheral vertigo than placebo
Piracetam 2.4 g/day (n = 25) Placebo (n = 25)

At baseline After 60 days treatment

80 76
% patients with symptom

72
68
64 64
60 52

40 32 32
28 28 28
24
20 20
20
0 0
0
Nystagmus Index Imbalance Star Nystagmus Index Imbalance Star
deviation gait deviation gait

Haguenauer JP. Les Cahiers dO.R.L 1986;21:4606.


Nootropils beneficial effect on vertigo
persists following treatment cessation
Piracetam 2.4 g/day Placebo
n = 89
Follow-up
During without
treatment treatment
number of vertigo episodes
Change from baseline in

5 Day 28 Day 56 Day 84

-5

-10
-15

-20
p<0.01 p<0.01 p<0.05

Adapted from Rosenhall U et al. Clin Drug Invest 1996;11:25160. Day 84 is 4 weeks after cessation of treatment.
Nootropil is well tolerated in
clinical trials
Incidence of adverse events (%) in pooled analysis (completed in 1997)
of 91 placebo-controlled trials

Adverse event Piracetam (n = 3017) Placebo (n = 2850)


Hyperkinesia 1.72 0.42
Weight increase 1.29 0.39
Nervousness 1.13 0.25
Somnolence 0.96 0.25
Depression 0.83 0.21
Asthenia 0.23 0.00

The good tolerability profile of Nootropil makes it suitable


for use in elderly populations
Nootropil monograph 2004.
CONCLUSIONS
1. Efficacy of Nootropil is not limited to a
particular vertigo cause
2. Nootropil has a beneficial effect on vertigo
episodes
3. Nootropil has a beneficial effect between
vertigo episodes
4. Nootropil has a beneficial effect on social and
professional functioning
Winblad B. CNS Drug Rev 2005;11(2):169-82. Nootropil monograph 2004.
PRACTICAL POINT
1. IS IT REALLY VERTIGO ?
(HEADACHE, PRESYNCOPE)
2. WHAT KIND OF VERTIGO?
VESTIBULARIS (CENTRAL VS PERIPHERAL)
NON VESTIBULAR
3. IDENTIFYING THE CAUSE.
CENTRAL VERTIGO: CEREBELLUM CEREBELLAR SYNDROM
BRAINSTEMDYSPHAGIA, DYSARTHRIA, DIPLOPIA
PERIPHERAL VERTIGO: BPPV, MENIERE, NEURONITIS, LABYRINTHITIS
4. TREATMENT: CURATIVE OR SYMPTOMATIC?
BETAHISTINE, FLUNARIZINE, PIRACETAM
5. PATIENT EDUCATION
PATIENT COMPLIANCE

1. PATIENT EDUCATION
2. EXPLAIN THE RISK
3. KEEP IN TOUCH
4. ENCOURAGEMENT
5. PAY ATTENTION
Terima kasih

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