Semin Neurol 2010; 30(2): 167-174
Yoon-Hee Cha1
1 Department of Neurology, University of California Los Angeles, Los Angeles, California
ABSTRACT
Migraine-associated vertigo has become a well-recognized disease entity diagnosed based on a clinical history of recurrent vertigo attacks unexplained by other central or peripheral otologic abnormalities, which occurs in the patient with a history of migraine headaches. There is no international agreement on what spectrum of symptoms should be covered under this diagnosis, or what terminology should be used. The headaches and vestibular symptoms of migraine-associated vertigo may not be temporally associated, which often obscures the association. Diagnostic tests usually show nonspecific abnormalities that are also seen in patients with migraine who do not experience vestibular symptoms. Management generally follows the recommended treatment of migraine headaches, and includes dietary and lifestyle modifications and medical treatment with β blockers, calcium channel blockers, and tricyclic amines. Small case series show that acetazolamide and lamotrigine appear to be more effective for the vertigo attacks than headaches. Vestibular rehabilitation has also been shown to be helpful in several studies. In this review, the epidemiologic and clinical features of the disorder, as well as the current state of knowledge on pathophysiology, diagnostic testing, and treatment are described.
Wednesday, March 31, 2010
Friday, March 26, 2010
Long-term follow-up of patients with posterior canal benign paroxysmal positional vertigo
Acta Oto-Laryngologica (Mar 2010)
Kansu L, Avci S, Yilmaz I, Ozluoglu LN
Abstract
Conclusions: Recurrence of posterior canal benign paroxysmal positional vertigo (PC-BPPV) developed in one-third of patients when followed for an average of 5 years from diagnosis. History of head trauma and Ménière's disease contributed significantly to recurrence (p<0.05). History of head trauma as an etiologic cause was more frequent in patients with recurrence of PC-BPPV.
Objectives: To estimate recurrence in the long-term follow-up of patients with PC-BPPV after successful canalith repositioning maneuvers, and to determine which factors contribute to recurrence.
Methods: The charts of 118 patients with PC-BPPV were reviewed. Data of patients were recorded from the initial evaluation and treatment. Follow-up was performed at mean of 64 +/- 7.7 months after the initial phase. The Dix-Hallpike maneuver was performed for diagnosis, and all patients were treated by the canalith repositioning maneuver, which was repeated every 3 days until the patients were symptom-free or results of the Dix-Hallpike maneuver were negative.
Results: At diagnosis, the most common etiology was idiopathic in 55 patients (46.6%). Recurrence occurred in 39 of 118 patients (33.1%). Recurrence occurred within the first 2 years in 21 of the 39 patients (53.8%). History of head trauma was a more frequent finding in patients who developed recurrence (12 of 39, 30.8%).
Kansu L, Avci S, Yilmaz I, Ozluoglu LN
Abstract
Conclusions: Recurrence of posterior canal benign paroxysmal positional vertigo (PC-BPPV) developed in one-third of patients when followed for an average of 5 years from diagnosis. History of head trauma and Ménière's disease contributed significantly to recurrence (p<0.05). History of head trauma as an etiologic cause was more frequent in patients with recurrence of PC-BPPV.
Objectives: To estimate recurrence in the long-term follow-up of patients with PC-BPPV after successful canalith repositioning maneuvers, and to determine which factors contribute to recurrence.
Methods: The charts of 118 patients with PC-BPPV were reviewed. Data of patients were recorded from the initial evaluation and treatment. Follow-up was performed at mean of 64 +/- 7.7 months after the initial phase. The Dix-Hallpike maneuver was performed for diagnosis, and all patients were treated by the canalith repositioning maneuver, which was repeated every 3 days until the patients were symptom-free or results of the Dix-Hallpike maneuver were negative.
Results: At diagnosis, the most common etiology was idiopathic in 55 patients (46.6%). Recurrence occurred in 39 of 118 patients (33.1%). Recurrence occurred within the first 2 years in 21 of the 39 patients (53.8%). History of head trauma was a more frequent finding in patients who developed recurrence (12 of 39, 30.8%).
Wednesday, March 17, 2010
Rotational vertebrobasilar insufficiency secondary to vertebral artery occlusion from fibrous band of the longus coli muscle
Neuroradiology, Volume 32, Number 6 / December, 1990
M. R. Dadsetan1 and H. E. I. Skerhut2
(1) Department of Radiology, Neuroradiology Section, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, 78284 San Antonio, Texas, USA
(2) Division of Neurosurgery, The University of Texas Health Science Center at San Antonio, Texas, USA
Received: 7 March 1989
Summary Rotation-induced vertebrobasilar artery hypoperfusion causes transient ischemic attacks (TIAs), affecting the cerebellum, brainstem and spinal cord. When these symptoms occur transiently due to head movement, compression of the vertebral artery by an extraluminal lesion should be suspected. Cervical spondylotic spurs and anterior scalene muscle or deep cervical fascia are among the factors which can compress the vertebral artery. When symptoms of vertebrobasilar insufficiency occur with rotational head movement, subclavian angiography for visualization of the entire vertebral artery in both neutral and rotated head positions should be undertaken.
M. R. Dadsetan1 and H. E. I. Skerhut2
(1) Department of Radiology, Neuroradiology Section, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, 78284 San Antonio, Texas, USA
(2) Division of Neurosurgery, The University of Texas Health Science Center at San Antonio, Texas, USA
Received: 7 March 1989
Summary Rotation-induced vertebrobasilar artery hypoperfusion causes transient ischemic attacks (TIAs), affecting the cerebellum, brainstem and spinal cord. When these symptoms occur transiently due to head movement, compression of the vertebral artery by an extraluminal lesion should be suspected. Cervical spondylotic spurs and anterior scalene muscle or deep cervical fascia are among the factors which can compress the vertebral artery. When symptoms of vertebrobasilar insufficiency occur with rotational head movement, subclavian angiography for visualization of the entire vertebral artery in both neutral and rotated head positions should be undertaken.
Rotational vertebral artery occlusion: a mechanism of vertebrobasilar insufficiency.
Neurosurgery. 1997 Aug;41(2):427-32; discussion 432-3.
Kuether TA, Nesbit GM, Clark WM, Barnwell SL.
Division of Neurosurgery, Oregon Health Science University, Portland, USA.
OBJECTIVE: Symptomatic dynamic changes in blood flow secondary to vertebral artery compression with rotational head motion are evaluated in a series of patients as a cause for posterior circulation transient ischemic attacks. These cases are classic examples of rotational vertebral artery occlusion and allow for the discussion of the anatomic basis, angiographic features, and treatment options. ILLUSTRATIVE CASES: In our series, symptoms of vertebrobasilar insufficiency were reproducible with rotational head movement. Compression of the vertebral artery was demonstrated angiographically. The correct site of occlusion of the vertebral artery was apparent only by dynamic angiography with progressive head rotation. All of the patients presented in the illustrative cases had occlusion at the C2 level; however, one patient had been previously misdiagnosed and another had an additional site of occlusion. The anatomic course of the vertebral artery is described in addition to the sites of rotational occlusion.
CONCLUSION: Rotational vertebral occlusion is an important cause of vertebrobasilar symptoms, which may lead to permanent neurological deficit if left undiagnosed. Dynamic angiography is the established method of diagnosis. Great care must be taken to avoid misdiagnosing the site of occlusion or missing a second occlusive site. For this reason, it is crucial to have a thorough understanding of the anatomic course of the vertebral artery and the muscular and tendinous insertions, which may cause rotational occlusion. The decision for treatment must be based on the site of occlusion as well as the assessment of the patient as a surgical candidate. A review of the literature reveals that surgical treatment is effective and must be considered to avoid further morbidity.
Kuether TA, Nesbit GM, Clark WM, Barnwell SL.
Division of Neurosurgery, Oregon Health Science University, Portland, USA.
OBJECTIVE: Symptomatic dynamic changes in blood flow secondary to vertebral artery compression with rotational head motion are evaluated in a series of patients as a cause for posterior circulation transient ischemic attacks. These cases are classic examples of rotational vertebral artery occlusion and allow for the discussion of the anatomic basis, angiographic features, and treatment options. ILLUSTRATIVE CASES: In our series, symptoms of vertebrobasilar insufficiency were reproducible with rotational head movement. Compression of the vertebral artery was demonstrated angiographically. The correct site of occlusion of the vertebral artery was apparent only by dynamic angiography with progressive head rotation. All of the patients presented in the illustrative cases had occlusion at the C2 level; however, one patient had been previously misdiagnosed and another had an additional site of occlusion. The anatomic course of the vertebral artery is described in addition to the sites of rotational occlusion.
CONCLUSION: Rotational vertebral occlusion is an important cause of vertebrobasilar symptoms, which may lead to permanent neurological deficit if left undiagnosed. Dynamic angiography is the established method of diagnosis. Great care must be taken to avoid misdiagnosing the site of occlusion or missing a second occlusive site. For this reason, it is crucial to have a thorough understanding of the anatomic course of the vertebral artery and the muscular and tendinous insertions, which may cause rotational occlusion. The decision for treatment must be based on the site of occlusion as well as the assessment of the patient as a surgical candidate. A review of the literature reveals that surgical treatment is effective and must be considered to avoid further morbidity.
Rotational vertebrobasilar ischemia: hemodynamic assessment and surgical treatment
Neurosurgery. 2005;56(1):36-43; discussion 43-5.
Vilela MD, Goodkin R, Lundin DA, Newell DW.
Harborview Medical Center and Department of Neurological Surgery, University of Washington, Seattle, Washington 98122, USA.
OBJECTIVE: Rotational vertebrobasilar insufficiency is a severe and incapacitating condition. Proper investigation and management are essential to reestablish normal posterior circulation hemodynamics, improve symptoms, and prevent stroke. We present a series of 10 patients with rotational vertebrobasilar ischemia who were treated surgically and emphasize the importance of transcranial Doppler in the diagnosis and management of this condition.
METHODS: All patients presented with symptoms of vertebrobasilar insufficiency induced by head turning. Transcranial Doppler documented a significant decrease in the posterior cerebral artery velocities during head turning that correlated with the symptoms in all patients. A dynamic cerebral angiogram was performed to demonstrate the site and extent of vertebral artery compression.
RESULTS: The surgical technique performed was tailored to each individual patient on the basis of the anatomic location, pathogenesis, and mechanism of the vertebral artery compression. Five patients underwent removal of osteophytes at the level of the subaxial cervical spine, one patient had a discectomy, two patients had a decompression only at the level of C1-C2, and two patients had a decompression and fusion at the C1-C2 level.
CONCLUSION: The transcranial Doppler is extremely useful to document the altered hemodynamics preoperatively and verify the return of normal posterior circulation velocities after the surgical decompression in patients with rotational vertebrobasilar ischemia. Surgical treatment is very effective, and excellent long-term results can be expected in the vast majority of patients after decompression of the vertebral artery.
PMID: 15617584 [PubMed - indexed for MEDLINE]
Vilela MD, Goodkin R, Lundin DA, Newell DW.
Harborview Medical Center and Department of Neurological Surgery, University of Washington, Seattle, Washington 98122, USA.
OBJECTIVE: Rotational vertebrobasilar insufficiency is a severe and incapacitating condition. Proper investigation and management are essential to reestablish normal posterior circulation hemodynamics, improve symptoms, and prevent stroke. We present a series of 10 patients with rotational vertebrobasilar ischemia who were treated surgically and emphasize the importance of transcranial Doppler in the diagnosis and management of this condition.
METHODS: All patients presented with symptoms of vertebrobasilar insufficiency induced by head turning. Transcranial Doppler documented a significant decrease in the posterior cerebral artery velocities during head turning that correlated with the symptoms in all patients. A dynamic cerebral angiogram was performed to demonstrate the site and extent of vertebral artery compression.
RESULTS: The surgical technique performed was tailored to each individual patient on the basis of the anatomic location, pathogenesis, and mechanism of the vertebral artery compression. Five patients underwent removal of osteophytes at the level of the subaxial cervical spine, one patient had a discectomy, two patients had a decompression only at the level of C1-C2, and two patients had a decompression and fusion at the C1-C2 level.
CONCLUSION: The transcranial Doppler is extremely useful to document the altered hemodynamics preoperatively and verify the return of normal posterior circulation velocities after the surgical decompression in patients with rotational vertebrobasilar ischemia. Surgical treatment is very effective, and excellent long-term results can be expected in the vast majority of patients after decompression of the vertebral artery.
PMID: 15617584 [PubMed - indexed for MEDLINE]
Rotational vertebrobasilar ischemia due to vertebral artery dynamic stenoses complicated by an ostial atherosclerotic stenosis
Vascular Medicine, Vol. 14, No. 3, 265-269 (2009)
DOI: 10.1177/1358863X08099707
Gregory W Natello
Department of Cardiology, William Jennings Bryan Dorn Veterans Affairs Medical Centergregnatello@gmail.com
Christine M Carroll Department of Cardiology, William Jennings Bryan Dorn Veterans Affairs Medical Center
Arabindra B Katwal Department of Internal Medicine, University of South Carolina – Palmetto Health Richland
Abstract
We describe a patient with rotational vertebrobasilar ischemia (RVBI) due to vertebral artery (VA) compressive stenoses during neck rotation, complicated by an ostial atherosclerotic stenosis (OAS). Referred for ‘near-syncopal spells’, inquiry revealed a symptom-complex consistent with vertebrobasilar transient ischemic attacks (TIAs) provoked by head rotation. VA dynamic angiography with imaging via prevertebral subclavian injections in neck-rotated positions while reproducing symptoms, demonstrated two compressive stenoses not present in the neck-neutral position, establishing the diagnosis of RVBI due to CT-demonstrated cervical spondylosis. There was an occluded contralateral VA, isolated posterior circulation, and absent vertebral collateral flow. Disabling symptoms persisted despite using a cervical collar. Surgical decompression of the dynamic stenoses would not address the OAS, was considered high risk, and absence of a suitable donor artery precluded distal VA reconstruction. RVBI resolved with ostial stent placement by improving perfusion pressure across the compressive stenoses. To our knowledge, this is the first report of RVBI in which the affected VA had an obstructive atherosclerotic stenosis in addition to the characteristic rotation-induced dynamic stenoses, and the first report of stent placement in the culprit artery to treat this disorder. Diagnosis depends on recognizing the association of symptoms with positional neck changes and VA dynamic angiography demonstrating the compressive stenosis while reproducing symptoms. This case illustrates the management complexities when there are coexisting abnormalities, emphasizing the need to individualize treatment. RVBI is a potentially correctable cause of TIAs and particularly relevant due to the aging population which has a significant incidence of both degenerative cervical and atherosclerotic cerebrovascular disease.
Key words: atherosclerosis, cerebral angiography, cervical osteophytes, dynamic angiography, imaging -- diagnostic, posterior-circulation transient ischemic attack, rotation-induced compressive stenosis, rotational vertebrobasilar ischemia, stents, vertebral artery
DOI: 10.1177/1358863X08099707
Gregory W Natello
Department of Cardiology, William Jennings Bryan Dorn Veterans Affairs Medical Centergregnatello@gmail.com
Christine M Carroll Department of Cardiology, William Jennings Bryan Dorn Veterans Affairs Medical Center
Arabindra B Katwal Department of Internal Medicine, University of South Carolina – Palmetto Health Richland
Abstract
We describe a patient with rotational vertebrobasilar ischemia (RVBI) due to vertebral artery (VA) compressive stenoses during neck rotation, complicated by an ostial atherosclerotic stenosis (OAS). Referred for ‘near-syncopal spells’, inquiry revealed a symptom-complex consistent with vertebrobasilar transient ischemic attacks (TIAs) provoked by head rotation. VA dynamic angiography with imaging via prevertebral subclavian injections in neck-rotated positions while reproducing symptoms, demonstrated two compressive stenoses not present in the neck-neutral position, establishing the diagnosis of RVBI due to CT-demonstrated cervical spondylosis. There was an occluded contralateral VA, isolated posterior circulation, and absent vertebral collateral flow. Disabling symptoms persisted despite using a cervical collar. Surgical decompression of the dynamic stenoses would not address the OAS, was considered high risk, and absence of a suitable donor artery precluded distal VA reconstruction. RVBI resolved with ostial stent placement by improving perfusion pressure across the compressive stenoses. To our knowledge, this is the first report of RVBI in which the affected VA had an obstructive atherosclerotic stenosis in addition to the characteristic rotation-induced dynamic stenoses, and the first report of stent placement in the culprit artery to treat this disorder. Diagnosis depends on recognizing the association of symptoms with positional neck changes and VA dynamic angiography demonstrating the compressive stenosis while reproducing symptoms. This case illustrates the management complexities when there are coexisting abnormalities, emphasizing the need to individualize treatment. RVBI is a potentially correctable cause of TIAs and particularly relevant due to the aging population which has a significant incidence of both degenerative cervical and atherosclerotic cerebrovascular disease.
Key words: atherosclerosis, cerebral angiography, cervical osteophytes, dynamic angiography, imaging -- diagnostic, posterior-circulation transient ischemic attack, rotation-induced compressive stenosis, rotational vertebrobasilar ischemia, stents, vertebral artery
Strategies to Distinguish Benign Paroxysmal Positional Vertigo from Rotational Vertebrobasilar Ischemia
Annals of Vascular Surgery, 02/05/10
Katherine D. Heidenreich1, Wendy J. Carender1, Michael J. Heidenreich2, Steven A. Telian1
Vertigo provoked by head rotation is a classic symptom of rotational vertebrobasilar ischemia (RVBI). Inner ear disease can cause positional vertigo and mimic RVBI. We review the case of a patient with vertigo consistently triggered by leftward head rotation when supine. Computed tomography angiogram and dynamic arteriogram failed to show compression of the vertebral arteries with head rotation. Further evaluation revealed benign paroxysmal positional vertigo (BPPV) as the underlying etiology. Treatment of her BPPV led to complete resolution of her symptoms. A succinct overview of this common otologic disorder is provided, and strategies to help distinguish it from RVBI are discussed.
Ann Arbor, Michigan
1 Division of Otology and Neurotology, Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health System, Ann Arbor, MI
1 Division of Otology and Neurotology, Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health System, Ann Arbor, MI
2 Department of General Surgery, Saint Joseph Mercy Hospital, Ann Arbor, MI
Correspondence to: Katherine D. Heidenreich, MD, Division of Otology and Neurotology, Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health System, 1904 Taubman Center, 1500 E. Medical Center Dr., SPC 5312, Ann Arbor, MI 48109-5312.
Katherine D. Heidenreich1, Wendy J. Carender1, Michael J. Heidenreich2, Steven A. Telian1
Vertigo provoked by head rotation is a classic symptom of rotational vertebrobasilar ischemia (RVBI). Inner ear disease can cause positional vertigo and mimic RVBI. We review the case of a patient with vertigo consistently triggered by leftward head rotation when supine. Computed tomography angiogram and dynamic arteriogram failed to show compression of the vertebral arteries with head rotation. Further evaluation revealed benign paroxysmal positional vertigo (BPPV) as the underlying etiology. Treatment of her BPPV led to complete resolution of her symptoms. A succinct overview of this common otologic disorder is provided, and strategies to help distinguish it from RVBI are discussed.
Ann Arbor, Michigan
1 Division of Otology and Neurotology, Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health System, Ann Arbor, MI
1 Division of Otology and Neurotology, Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health System, Ann Arbor, MI
2 Department of General Surgery, Saint Joseph Mercy Hospital, Ann Arbor, MI
Correspondence to: Katherine D. Heidenreich, MD, Division of Otology and Neurotology, Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health System, 1904 Taubman Center, 1500 E. Medical Center Dr., SPC 5312, Ann Arbor, MI 48109-5312.
Non-invasive evaluation of vertebral artery blood flow in cervical spondylosis with and without vertigo and association with degenerative changes
Clinical Rheumatology 0770-3198 (Print) 1434-9949 (Online), Published online: 16 February 2010
Remzi Cevik1 , Aslan Bilici2, Kemal Nas1, Zeynep Demircan1 and Rojbin Ceylan Tekin2
(1) Department of Physical Medicine and Rehabilitation, Faculty of Medicine, University of Dicle, 21280 Diyarbakir, Turkey
(2) Department of Radiology, Faculty of Medicine, University of Dicle, Diyarbakir, Turkey
Received: 31 May 2009 Revised: 4 January 2010 Accepted: 8 January 2010
Abstract Cervical spondylosis is a common disease that results from degenerative changes of the cervical spine and vertigo may occur in this process.
The aim of the present study was to assess the blood flow measurements of the vertebral artery (VA) using color Doppler ultrasonography (CDUS) in patients who have cervical spondylosis with and without vertigo. The study population included 101 patients with vertigo and spondylosis, 66 patients with spondylosis without vertigo, and 62 healthy controls. A bilateral decrease in the VA blood flow velocities were measured in patients with cervical spondylosis.
A negative correlation was found between the stage of cervical degenerative changes and the flow velocities in patients with vertigo, while this relationship was not found in patients without vertigo.
The CDUS evaluation of the pretransverse and transverse segments of VAs demonstrated significantly reduced flow velocities in patients with spondylosis.
The degenerative changes in the cervical spine seem to be related to these velocity changes in the subgroup of patients who are also affected with vertigo. The pretransverse segment of the VA provides valuable measurements as well as transverse segment of the VA, and it can be used as an appropriate segment for CDUS examination in cervical spondylosis and associated vertigo.
Remzi Cevik1 , Aslan Bilici2, Kemal Nas1, Zeynep Demircan1 and Rojbin Ceylan Tekin2
(1) Department of Physical Medicine and Rehabilitation, Faculty of Medicine, University of Dicle, 21280 Diyarbakir, Turkey
(2) Department of Radiology, Faculty of Medicine, University of Dicle, Diyarbakir, Turkey
Received: 31 May 2009 Revised: 4 January 2010 Accepted: 8 January 2010
Abstract Cervical spondylosis is a common disease that results from degenerative changes of the cervical spine and vertigo may occur in this process.
The aim of the present study was to assess the blood flow measurements of the vertebral artery (VA) using color Doppler ultrasonography (CDUS) in patients who have cervical spondylosis with and without vertigo. The study population included 101 patients with vertigo and spondylosis, 66 patients with spondylosis without vertigo, and 62 healthy controls. A bilateral decrease in the VA blood flow velocities were measured in patients with cervical spondylosis.
A negative correlation was found between the stage of cervical degenerative changes and the flow velocities in patients with vertigo, while this relationship was not found in patients without vertigo.
The CDUS evaluation of the pretransverse and transverse segments of VAs demonstrated significantly reduced flow velocities in patients with spondylosis.
The degenerative changes in the cervical spine seem to be related to these velocity changes in the subgroup of patients who are also affected with vertigo. The pretransverse segment of the VA provides valuable measurements as well as transverse segment of the VA, and it can be used as an appropriate segment for CDUS examination in cervical spondylosis and associated vertigo.
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