Curiculum Vitae

Curiculum Vitae Nama Jabatan

: dr.Endang Kustiowati SpS(K) :Ka.TKP.PPDS UNDIP KPS Bagian Neurologi FK UNDIP Status : Riwayat pendidikan : Lulus S1 FK UNDIP 1985 Lulus SpS FK UNDIP 1995 SpS(K) KNI 2003 Riwayat pekerjaan : Staf bagian Neurologi FK UNDIP Riwayat organisasi : Koordinator Nasional POKDI Epilepsi PERDOSSI Sekretaris PERDOSSI cab Semarang

CENTRAL VERTIGO Endang Kustiowati Dept. of Neurology Diponegoro University-Kariadi Hospital Semarang

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Central vertigo is vertigo due to a disease originating from CNS. It often includes lesions of cranial N.VIII as well. Individuals with vertigo experience hallucinations of the motion of their surroundings Central vertigo may be caused by hemorrhagic or ischemic insults to the cerebellum, the vestibuler nuclei, and their conections within the brain stem. Other causes include CNS tumors, infection, trauma and multiple sclerosis

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Pathophysiology. The brain stem, cerebellum, and peripheral labyrinths are all supplied by the vertebrobasiler arterial system. Thus, the central and peripheral ischemic vertigo syndromes overlap

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Pathophysiology. Sensation of balance is the result of appropriate information that is detected by the vestibuler, ocular, and proprioseptive sensory reseptors and then properly integrated within the cerebellum and brain stem. Proper gait, posture, and visual focus during head movement are all dependent on an intact sense of balance. Loss of sensory information, central integration, or out put control mechanisms all result in a sense of imbalance

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Central causes of vertigo result from either a disruption of central integrators ( brain stem, cerebellum) or a sensory information mismatch (from cortex)

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Lesions affecting the vestibular nerve or root entry zoon (cerebellopontine angle lesions) result in imbalance by affecting primary vestibular sensory information

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Race : No racial predilection exists for CNS causes of vertigo

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Sex : Men and women are affected differently by different causes of CNS vertigo. Vestibular migraine, shows a predilection for women

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Age: CNS causes of vertigo typically affect older population groups because of the associated risk factors of vascular causes of vertigo, such as hypertension, atherosclerosis, and diabetes mellitus

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Age Younger population groups are more commonly affected by migraine headaches and multiple sclerosis Cerebeller tumors affect a bimodal population of children and adults CPA tumors typically affect people in the fifth to eighth decades of life

CENTRAL VERTIGO Associated symptoms are present, they may suggest the nature of the underlying disease Peripheral vertigo presents with the following: - Associated nausea - Vomiting - Auditory complaints - Abrupt onset

CENTRAL VERTIGO Central vertigo often produces other neurologic symptoms are characterized as follows : - Gradual onset - Tend to be much less intense than those associated with peripheral vertigo

CENTRAL VERTIGO In assessing the possibility of central vertigo related to cerebrovascular disease, inquire about important risk factors : - Hypertension - Atrial fibrillation - History of prior CVA - Advanced age

CENTRAL VERTIGO Physical A thorough neurologic and cardiologic examination is important Depressed consciousness my be due to disease such as infarction within the brain stem or external compression Cerebeller infarction, brainstem compression is found more often in those who have involvement of the posterior inferior cerebellar artery

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Nystagmus Horizontal nystagmus the most common type of nistagmus observed in patients with cerebeller infarction Vertical nystagmus is considered specific for central vertigo

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Physical Nystagmus of central origin characteristically is worsened by fixation of gaze, while peripheral nystagmus may be ameliorated

CENTRAL VERTIGO Physical Cardiac examination may reveal arrhytmia as the cause of symptoms Gaze-evoked nystagmus, and severe truncal ataxia with limb incoordination are findings associated with cerebellar infarction Decreased gag reflex, facial numbness, horner syndrome, and dysphonia are associated signs indicating brainstem damage.

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CPA tumors. - Cause vertigo also cause unilateral hearing loss and my occur with nystagmus - A head thrust test may reveal unilateral vestibular weakness. - A large tumors may cause subtle facial weakness, decrease corneal reflex, and facial disesthesia

CENTRAL VERTIGO Physical Potential central abnormality is the cause of the vertgo : - Spontaneous nystagmus that cannot be suppressed with visual fixation; - Nystagmus that changes direction with gaze ; purely vertical, horizontal, or torsional; and dysmetria (overshoot and undershoot)

CENTRAL VERTIGO Physical Paroxysmal positional nystagmus that is of central origin ussually does not decrease with repeated positioning maneuvers, has no latency of onset, last longer than 60 seconds, is often vertical in direction, and may change direction with different head positions

CENTRAL VERTIGO Causes  Cerebrovascular disease of the posterior circulation - Basilar artery occlusion - Vertebral artery occlusion - Acute cerebellar disease  Cranial nerve deficits  Meniere disease and acoustic neuroma

CENTRAL VERTIGO Causes Central vertigo syndromes resulting from acute vascular events most commonly result from a combination of hypertension and regional atherosclerosis Less commonly, arterial dissection secondary to neck extension, rotational injury, or osteoarthritic spurs is the cause of disturbed posterior fossa blood flow Migraine headache and presyncopal lightheadachness are two forms of regional and global ischemia that may appear with vertigo are imbalance as the primary symptom

CENTRAL VERTIGO Imaging Studies Imaging of the posterior fossa is necessary if the clinician suspects a central lesion  MRI is preferred modality to detect infarction, hemorrhage, tumor, multiple sclerosis  MRA  Doppler Ultrasonography

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Other Tests Electrocardiography Electronystagmography Audiometry Brainstem Auditory Evoked Response (BAER)

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Medical Care Medical treatment includes supportive care with fluid replacement and vestibular suppressants for intractable vertigo with nausea and vomiting Control of hypertension, diabetes mellitus, and atherosclerosis , Cardiac arrhythmia Treatment of vertebrobasilar insufficiency

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Surgical Care Surgical treatment of central vertigo is limited to urgent posterior fossa decompression of cerebellar and brainstem edema complicated CPA tumors are surgically removed on an elective basis. If a medical contraindication exists, radiotherapy for tumor control is an option

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Consultations Otolaringologists, neurosurgeons, neurologists, and cardiologists are consulted for further diagnosis and treatment of vertigo of CNS origin

CT scan of a patient with an acute spontaneous cerebellar hemorrhage. The hemorrhage in the right lobe of the cerebellum is partly obscured by bony artifact.

MRI of a patient with an acute cerebellar hemorrhage less than 24 hours after presentation. MRI allows better resolution than CT scan without bony artifact. MRI is preferred over CT scan for imaging lesions in the posterior fossa.

CT scan of a patient with a large acoustic neuroma on the right side of the brain stem. The scan was performed after injection of intravenous contrast, which is critical for identifying tumors with CT imaging.

CT slice through the brain of a patient with an acoustic neuroma. This slice reveals a level of the brain higher than the acoustic neuroma. The dilated third and lateral ventricles provide gross evidence of obstructive hydrocephalus due to pressure exerted by the tumor on the brain stem. A ventriculostomy, seen as a white circle in the right lateral ventricle, has been placed in an attempt to drain cerebrospinal fluid and relieve the excessive pressure above the brain stem.