The treatment and natural course of peripheral and central vertigo

Abstract

Background: Recent studies have extended our understanding of the pathophysiology, natural course, and treatment of vestibular vertigo. The relative frequency of the different forms is as follows: benign paroxysmal positional vertigo (BPPV) 17.1%; phobic vestibular vertigo 15%; central vestibular syndromes 12.3%; vestibular migraine 11.4%; Menière's disease 10.1%; vestibular neuritis 8.3%; bilateral vestibulopathy 7.1%; vestibular paroxysmia 3.7%.

Methods: Selective literature survey with particular regard to Cochrane reviews and the guidelines of the German Neurological Society.

Results: In more than 95% of cases BPPV can be successfully treated by means of liberatory maneuvers (controlled studies); the long-term recurrence rate is 50%. Corticosteroids improve recovery from acute vestibular neuritis (one controlled, several noncontrolled studies); the risk of recurrence is 2-12%. A newly identified subtype of bilateral vestibulopathy, termed cerebellar ataxia, neuropathy, and vestibular areflexia syndrome (CANVAS), shows no essential improvement in the long term. Long-term high-dose treatment with betahistine is probably effective against Menière's disease (noncontrolled studies); the frequency of episodes decreases spontaneously in the course of time (> 5 years). The treatment of choice for vestibular paroxysmia is carbamazepine (noncontrolled study). Aminopyridine, chlorzoxazone, and acetyl-DL-leucine are new treatment options for various cerebellar diseases.

Conclusion: Most vestibular syndromes can be treated successfully. The efficacy of treatments for Menière's disease, vestibular paroxysmia, and vestibular migraine requires further research.

Figure 1

Endolymphatic hydrops as seen on high-resolution magnetic resonance imaging of the petrosal bone 24 h after transtympanic injection of gadolinium, which diffuses predominantly into the perilymphatic space. a) The labyrinth of a healthy control: The cochlea and semicircular canals are visualized. b) The labyrinth of a patient with Menière’s disease: the endolymphatic hydrops can be recognized by virtue of its lack of contrast medium uptake. With kind permission by Robert Gürkov

Figure 1

Endolymphatic hydrops as seen on high-resolution magnetic resonance imaging of the petrosal bone 24 h after transtympanic injection of gadolinium, which diffuses predominantly into the perilymphatic space. a) The labyrinth of a healthy control: The cochlea and semicircular canals are visualized. b) The labyrinth of a patient with Menière’s disease: the endolymphatic hydrops can be recognized by virtue of its lack of contrast medium uptake. With kind permission by Robert Gürkov

Figure 2

The relationship between cochlear blood flow and betahistine hydrochloride dosage in an animal experiment (nonlinear regression curve; mean ± SD; * p < 0.05) and the calculated corresponding oral single doses (modified from [35]). The sigmoidal dose–effect curve correlates with the higher doses of up to 160 mg betahistine (red line) used clinically to prevent Menière’s disease

Figure 3

Magnetic resonance imaging and intraoperative microscopy in a patient with right-sided vestibular paroxysmia a) High-resolution MRI of the cerebellopontine angle depicting the contact between the vestibulocochlear nerve (N. vest.) and the anterior inferior cerebellar artery (constructive interference in steady state [CISS] sequence) b) Time-of-flight (TOF) sequence for improved visualization of vessels; AICA, anterior inferior cerebellar artery c) The vessel–nerve contact is also seen intraoperatively d) Distinct compression of the vessel after removal of the vestibulocochlear nerve (circle) (modified from [38]) With kind permission by Lippincott Williams & Wilkins