vertigo dr. hartono p
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referat vertigoTRANSCRIPT
VERTIGO
Hartono Prabowo
Bagian Neurologi RS. Mayapada
Tangerang
Diajukan dalam Banten Neurology Update, 1 Nov 2014
VERTIGO Definisi :
Suatu sensasi ilusi atau halusinasi gerakan dari lingkungan atau diri sendiri, biasanya berupa gerakan berputar atau goyang.
Akibat adanya gangguan pada sistem keseimbangan
Vertigo bukan penyakit tetapi merupakan
gejala dari beberapa kelainan atau penyakit
Vertigo
• Wanita : Pria = 76 : 49 (3: 2).
• Usia : 20 – 30 th : 10%
30 – 39 th : 18%
40 – 49 th : 21%
50 – 59 th : 15%
>60 th : 35%
Menopause : 53%
• Komorbid : hipertensi (42%)
dislipidemia (42%)
merokkok (19%)
Vertigo
Vertigo Course 190113
Vestibular vertigo (True vertigo)
Non-vestibular vertigo
Peripheral vertigo Central vertigo
• Kelainan telinga dalam
• Kelainan Labyrinth / N. vestibularis
• Kelainan Batang otak / cerebellum
Visual dan somatosensoris
Anxiety / phobia / refraction anomalies
Vertigo Course 190113
Nistagmus Perifer Sentral
Arah nistagmus Satu arah,fase cepat mengarah kesisi normal
Kadang2 mengarah sebaliknya apabila pasien melirik kekomponen lambat
Tipe nistagmus Horizontal dgn komponen torsi
Dapat kearah mana saja
Efek fiksasi pandangan
SUPRESI Non-supresi
Gejala neurologis lain
Tidak ada Kadang ada
Instabilitas postural Satu arah instabilitas kec berjalan
Instabilitas berat meskipun berjalan
Tuli / tinitus Kemungkinan ada Tidak ada
Vertigo Course 190113
Gejala / tanda Perifer Sentral
Latency 0-40 detik (mean 7.8) Tidak ada periode
Latency
Duration Kurang dari 1 menit Gejala dapat
menetap
Fatigability
(Habituation) Ya (87%) Tidak ada
Reproducibility Tidak konsisten Lebih konsisten
Posisional Pada perobahan posisi Tidak posisional
Intensitas Sedang - berat Ringan
Serangan vertigo Berulang Terus menerus
Input Visual
Input
Proprioseptik
Input Vestibular
labyrinth
Keseimbangan
• Deep tendon reflex
• Functional stretch response
• Cervical proprioception
• Saccades
• Smooth pursuit
• Optokinetic reflex
• Depth perception
10 10
Balance requires information of similar intensity from both vestibular systems
Head movement
Activation of cells
in right vestibular
system
Activation of cells
in left
vestibular system
Normally, the input from left and right vestibular
system is of similar intensity (e.g. of size ‘10’)
Central nuclei
Peripheral vestibular vertigo Dysfunction of vestibular apparatus, vestibular nerve
5
Central nuclei
10
Central Vestibular Vertigo dysfunction in central processing
10 10
Central nuclei
Telinga Dalam
Vertigo Course 190113
Utrikulus dan otokonia ("ear
rocks") → aktivasi serabut saraf
menimbulkan impuls ke otak
dengan persepsi gerakan
dalam bidang datar
Sakulus → mengirimkan
impuls ke otak tentang
gerakan dalam bidang vertikal
→ mempertahankan tubuh
Kanalis Semisirkularis Memberikan respons terhadap gerakan sesuai dengan bidang kanalis tersebut
Pathophysiology
Vertigo Course 190113
Cortex
Neural store
Motor control System
Vomiting centre
Comporator
Sensory Integration
Visual input
Somatosensory input
Vestibular Input
Cholinergic system
Histaminergic system
PATHOPHYSIOLOGY OF VERTIGO
Brainstem
Brain
Labyrinth
Spinal
cord
Pusat Otonon
Nukl. vestibulars
N. III/IV/VI → VOR
Nystagmus, Oscillopsia
Gaster Mual, muntah
Jantung Palpitasi
Kel. keringat Keringat ↑
Vestibulospinal Disequilibrium / unsteadiness
Vertigo
Vertigo of Peripheral origin: causes
Condition Details
Benign paroxysmal
positional vertigo
(BPPV)
Brief, position-provoked vertigo episodes caused by
abnormal presence of particles in semicircular canal
+ 50%
Meniere’s disease An excess of endolymph, causing distension of
endolymphatic system, + 10-20%
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
concussion
Damage to the labyrinthine after head trauma
Perilymph fistula Typically caused by labyrinth membrane damage
resulting in perilymph leakage into the middle ear
Autoimmune inner
ear disease
Inappropriate immunological response that attacks inner
ear cells Decre
asin
g f
req
uen
cy
Baloh RW. Lancet 1998;352:1841–6. 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;99:316–21. Salvinelli F et al. Clin Ter 2003;154:341–8.
Vertigo of Central origin: causes
Condition Details
Migraine Vertigo may precede migraines or occur
concurrently
Vascular disease Ischaemia or haemorrhage in vertebrobasilar
system can affect brainstem or cerebellum
function
Multiple sclerosis Demylination disrupts nerve impulses which
can result in vertigo
Vestibular
epilepsy
Vertigo resulting from focal epileptic discharges
in the temporal or parietal association cortex
Cerebellopontine
tumours
Benign tumours in the internal auditory meatus
Decre
asin
g f
requency
Baloh RW. Lancet 1998;352:1841–6. Mukherjee A et al. JAPI 2003;51:1095-101. Salvinelli F et al. Clin Ter 2003;154:
341–8. Solomon D. Otolaryngol Clin North Am 2000;33:579–601. Strupp M, Arbusow V, Curr Opin Neurol 2001;14:11–20.
AAN 2010
Benign paroxysmal positional vertigo (BPPV)
• Paling sering, 10,7-64/100.000 kasus
• 2,4% populasi pernah mengalami vertigo • Prevalensi meningkat dengan umur (50-60 th),
Wanita : Pria = 3.1: 2.1 (berhubungan dengan osteopenia / osteoporosis dan defisiensi vit D)
• Matutinal vertigo (tu. pagi hari)
• Solomon D. Benign Paroxysmal Positional Vertigo. Current Treatment Options in Neurology. 2000, 2:417–427 • Hain C T. Vestibular Disorders Association • N Engl J Med 2014;370:1138-47
BPPV
• khas : Sensasi berputar Singkat (kurang dari 1 menit)
Dipicu oleh perobahan posisi kepala
yang dipengaruhi gravitasi
• Biasanya disertai mual / muntah
• Dapat menghilang beberapa minggu/bulan untuk kemudian timbul kembali
• 15% recurrent • Canalithiasis
• Solomon D. Benign Paroxysmal Positional Vertigo. Current Treatment Options in Neurology. 2000, 2:417–427 • N Engl J Med 2014;370:1138-47 • Hain C T. Vestibular Disorders Association
• 60-90% berkaitan dengan kanalis semisirkularis posterior (the most gravity - dependent canal)
• BPPV jarang melibatkan kanalis semisirkularis anterior → kemungkinan karena posisinya pada labyrinth paling atas sehingga otokonia (debris otolit jarang tersangkut didalamnya)
BPPV
• N Engl J Med 2014;370:1138-47
• NEUROLOGY 2004;63:150–152
• Hain C T. Vestibular Disorders Association
• Migrasi Otokonia dari utrikulus → Kanalis semisirkularis (tu posterior)
• Pada gerakan kepala → otokonia bergeser dan menimbulkan stimulasi pada kupula yang pada akhirnya akan menimbulkan signal yang salah ke otak → vertigo
Kanalis semisirkularis - Vertigo
• Hain C T. Vestibular Disorders Association
• Solomon
Faktor predisposisi BPPV
• Umur
• “Inactivity”
• Trauma
• Neuritis vestibular
• Riwayat keluarga dengan BPPV
• Posisi kepala tertentu yang terlalu lama (prosedur dokter gigi, salon kecantikan, dll)
• 20% dengan kelainan telinga lain spt Meniere’s syndrome
Solomon D. Benign Paroxysmal Positional Vertigo. Current Treatment Options in Neurology. 2000, 2:417–427
Cairan endolymph Impuls
Patogenesis
Sensasi gerakan kepala
• Hain C T. Vestibular Disorders Association
• Solomon
BPPV - DD
N Engl J Med 2014;370:1138-47
Terapi BPPV
• Pada umumnya BPPV mengalami perbaikan spontan
– Kanalis semisirkularis horizontal : 7 hari
– Kanalis semisirkularis posterior : 17 hari
• Canalith-repositioning Treatment → efektip
• Operatip
N Engl J Med 2014;370:1138-47
Terapi BPPV
• Farmakologis (terutama utk terapi mual dan muntah)
• Prosedur intervensi
– Dix-Hallpike test → PSC BPPV
– The Epley Maneuver
– Semont Maneuver
– Brandt Daroff Maneuver
• Operasi (Semicircular canal occlusion and singular neurectomy)
• Solomon D. Benign Paroxysmal Positional Vertigo. Current Treatment Options in Neurology. 2000, 2:417–427 • N Engl J Med 2014;370:1138-47
• Eliminasi Vertigo
• Kompensasi vestibuler
• Mengurangi gejala
neurovegetatip
• Mengurangi gejala
psikologis
TERAPI VERTIGO
Baloh RW. Lancet 1998;352:1841–6. Mukherjee A et al. JAPI 2003;51:1095-101.
Simptomatik Farmakoterapi (Antivertigo, antiemetik) + psikoafektip
Terapi spesifik • Farmoterapi • Operatip
Rehabilitatip VRT (Vestibular Rehabilitation Therapy)
Pencegahan faktor resiko
Kontrol diit, pola hidup, medikamentosa
Anticholinergics fisiologis Scopolamine
Antihistamines fisiologis Dimenhydrinate, Diphenhydramine, Meclizine
Calcium Channel Blockers
fisiologis Cinnarizine, Flunarizine, Nimodipine
Antidopaminergic Tanquilizer, neurovegetatip, psikoafektip
Chlorpromazine, Promethazine, Prochlorperazine
Gaba-ergic Anti anxietas / panik Diazepam, Lorazepam
Mono-aminergic Modulasi simpatetik Ephedrine
VASODILATORS Blood flow Nicotinic Acid, Betahistine, Carbogen (5% CO2 and 95% O2) Almitriptyline-Raubasine Gingko biloba
Vertigo Course 190113
FARMAKOTERAPI Vertigo
CHRONIC VERTIGO DRUGS
• Drugs with general arousal effect:
amphetamines, caffeine, ACTH
• contraindicated due to side effects
• Drug which facilitates compensation mechanisms
PIRACETAM (Nootropil ®)
VESTIBULAR REHABILITATION THERAPY
canalith repositioning procedures (CRPs)
Kanalis Semisirkularis
Terkait
Metode Efektifitas
Posterior • Epley (1 sesi 80% setelah diulang 92%)
• Semont
• 95% • 58%
Horizontal • The barbecue rotation • The Vannucchi’s forced
prolonged position • The Gufoni’s maneuver • Head shaking • Modified Semont
• 38% • 76% • 89% • 62% • 37%
Treatment for BPPV
canalith repositioning procedures (CRPs)
• N Engl J Med 2014;370:1138-47
• NEUROLOGY 2004;63:150–152
G
AG
N Engl J Med 2014;370:1138-47
EPLEY MANEUVER ( Canalith repositioning maneuver )
The Epley Maneuver
Solomon D. Benign Paroxysmal Positional Vertigo. Current Treatment Options in Neurology. 2000, 2:417–427
MEP (Modified Epley Procedure) (LPCBPPV)
Vertigo Course 190113 Neurology 2004;63;150-152
Semont's maneuver
N Engl J Med 2014;370:1138-47
Modified Semont’s Maneuver (LPCBPPV)
Solomon D. Benign Paroxysmal Positional Vertigo. Current Treatment Options in Neurology. 2000, 2:417–427
NEUROLOGY 2004;63:150–152
The Brandt-Daroff Maneuver
• Solomon D. Benign Paroxysmal Positional Vertigo. Current Treatment Options in Neurology. 2000, 2:417–427 • Vertigo Course 190113
Guidelines
• Practice guidelines published in 2008 independently by the American Academy of Neurology and the American Academy of Otolaryngology– Head and Neck Surgery1 recommend only the use of Epley’s maneuver for BPPV involving the posterior canal.
• Recommendations in this article include other maneuvers (Semont’s maneuver for BPPV involving the posterior canal and several other maneuvers for BPPV of the horizontal canal); these recommendations are based on data from more recent randomized trials
N Engl J Med 2014;370:1138-47
Kesimpulan
Vertigo akut adalah kasus gawat darurat
Pengobatan vertigo bersifat simtomatis dan kausatip
Obat mengandung Anti Histamine, Calcium Channel Blocker, GABA-ergic, Vasodilator, anti dopaminergik, monoaminergik
dapat digunakan. Anxiolitik dapat diberikan untuk waktu pendek untuk mencegah adiksi
CRP sangat bermanfaat untuk terapi BPPV
Kelainan yang mendasari seperti Stroke Vertebrobasilar, Autoimmune Disease tidak boleh dikesampingkan