Vertebral Basilar Insufficiency

VBI
?5% OF DIZZY CLINIC VISITS?
MUST ALWAYS THINK OF IT AS A POSSIBLE CAUSE OF ANY VERTIGO!--EVEN ISOLATED VERTIGO
IT HAS BEEN SAID TO IMAGE ANY ONE OVER 45----AT LEAST CONSIDER IT
MANY DISTINCT ENTITIES BUT FELLOW TRAVELERS OFTEN INCLUDE: DIPLOPIA, DYSPHAGIA, DYSARTHRIA, AND CROSSED FINDINGS (IPSI FACIAL DEFICITS AND ATAXIA WITH CONTRALATERAL BODY FINDINGS)
POST FOSSA MIGRAINE (RARE)
VESTIBULAR MIGRAINE=VASOSPASTIC VERTIGO= 1 VARIANT OF COMPLICATED MIGRAINE
USUALLY MINUTES TO HOURS
NO HEARING LOSS
NL ENT EXAM
NL NEURO EXAM, NL EEG----DIFF Dx = VERTIGINOUS TEMPORAL LOBE (ASTATIC) SEIZURES---ABNL EEG
AGE RELATED CLASSIFICATION
INFANTS (4 MO --- 12-16 MO)
PAROXYSMAL TORTICOLLIS---PREDISPOSED TO MIGRAINE
CHILDREN (12MO----4-5YRS)
BENIGN PAROXYSMAL VERTIGO OF CHILDHOOD
USUALLY MINUTES TO HOURS
SHORT DURATION---USUALLY NO HL
20% SPONT NYSTAGMUS DURING ATTACKS
MILD UNILATERAL HYPOACTIVITY ON ENG
NO HA
ATTACKS RECUR WITH DIMINISHED FREQ
ADOLESCENCE/ADULTHOOD
BASILAR ARTERY (BICKERSTAFF’S) MIGRAINE/ VESTIBULAR MIGRAINE
70% TRUE VERTIGO/ 30% VAGUE DYSEQUILIBRIUM AND MOTION INTOLERANCE
5% DIRECT ASSOC OF VERTIGO WITH HA
65% VARIABLE ASSOC
30% NO ASSOC OF VERTIGO WITH HA
HIGHLY LINKED WITH PMS (FEMALE PREPONDERANCE)
USUALLY MINUTES TO HOURS
25% HAVE A UNILAT WEAKNESS ON ENG
HIGHLY LINKED WITH FOOD ALLERGY (WATCH FOR PROVOKATIVE FOODS)
SUBCLAVIAN STEAL---VBI EITH U E EXCERSICES
VERTEBRAL ARTERY DISSECTION----FOLLOWING A VISIT TO THE CHIROPRACTOR
C-SPINE ABNL---VERTEBRALS ENTER THE TRANSVERSE FORAMINA AT C-6
LISTEN FOR A SUPRACLAVICULAR BRUIT---DUPLEX CAN ASSES THE PRESENCE AND DIRECTION OF FLOW
MUST DIFF CERVICAL SPONDYLOSIS FROM CERVICAL VERTIGO
CARDIOGENIC----VERTEBRAL BASILAR SYSTEM IS VERY SUSCEPTIBLE TO CPP
VASO-OCCLUSIVE DISEASE
RISK FACTORS--HTN, HYPERLIPIDEMIA, AGE, OBESITY, D.M., +FH, SMOKERS, ETC.
ACUTE RAPID ONSET
VASCULAR TIME FRAME---MINUTES
CHRONIC “LACUNAR SYNROME”--MULT SMALL LACUNAR INFARCTS--”PRESBYSTASIS”
20% OF PTS WITH VBI HAVE DIZZINESS AS ISOLATED INITIAL Sx
2/3 OF PTS WITH VBI HAVE DIZZINESS
DIZZINESS IS A COMMON BUT NON-SPECIFIC SYMTOM
LATEROPULSION---IPSI=PICA, CONTRA=SUP CEREBELLAR ARTERY
HIGH INCIDENCE OF FELLOW TRAVELERS--HICCUPS, ATAXIA, VISUAL FIELD DEFICITS, DYSARTHRIA, DYSPHAGIA---”BROWN OUT”, HALLUCINATIONS, SCINTILLATING SCOTOMA, VERTICAL DIPLOPIA, DISTORTION OF VERTICALITY(SKEWED DEVIATION)
DIZZY, DIPLOPIA, DYSARTHRIA, DYSPHAGIA----HIGH INCIDENCE OF CROSSED FINDINGS!
IPSI FACIAL FINDINGS (DECREASED P/T, HORNERS, PHARYNX AND LARYNX)--LESION BELOW THE DECUSSATION OF THE FACIAL FIBERS
CONTRA BODY FINDINGS (DECREASED P/T)
LESION ABOVE THE PYRAMIDAL DECUSSATION
IPSILAT ATAXIA---FALL TOWARDS THE LESION
IPSI CEREBELLAR STRUCTURES
ASK FOR PROVAKATIVE DYNAMIC VERTEBRAL DUPLEX STUDY
PICA---WALLENBURG’S SYNDROME---LAT. MEDULLARY SYNDROME
LATEROPULSION---SACCADIC IPSIPULSION--SACCADES OVERSHOOT TO THE SIDE OF THE LESION AND UNDERSHOOT CONTRALATERALLY
STEADY STATE DEVIATION OF CLOSED EYES (FRENZELS) TO THE SIDE OF THE LESION
OTOLITH SYNDROME---SKEWED DEVIATION (IPSI EYE LOWER)--DISTORTED PERCEPTION OF VERTICALITY
HOARSENSS--DORSAL MOTOR NUCLEUS----HORNERS SYNDROME
CAN GET VESTIBULAR MASSETER SYNDROME---MOTOR NUC OF V--WEAKNESS AND DEVIATION OF THE JAW
IPSI CN 8---TINNITUS, SNHL, LOSS OF CALORICS
IPSI CN 7---FACIAL PARESIS
AICA
COMMONLY VERTIGO WITHOUT THE HL IS THE AICA TIA
SUP CEREBELLAR ARTERY SYNDROME
SACCADIC CONTRALATEROPULSION----SACCADES OVERSHOOT CONTRALATERAL TO THE LESION
PARALYTIC PONTINE EXOTROPIA “THE 1 ½ SYNDROME”--NO EOMI
ANT. VESTIBULAR ARTERY OCCLUSION---VERTIGO WITH NO SNHL
LABYRINTHIAN APOPLEXY---THROMBOSIS OF THE INT AUD ARTERY (LABYRINTHIAN ARTERY)---VERTIGO, N/V, +SNHL