Instrumentally documented 20 types of dizziness, approach to individual therapy


Introduction. It has been reported that “more then 20% of general population aged 18 to 65 reported experiencing dizziness within the previous month. Half of those reported some degree of handicap associated with dizziness” [2]. Authors identify dizziness in different manner: “Any vague sensations of discomfort in the head can be described as dizziness” [3]. Or “vertigo – a disturbance in which the individual has a subjective impression of movement in space (subjective vertigo) or objects moving around him (objective vertigo), usually with a loss of equilibrium.

True vertigo is distinguished from faintness, light-headedness, or other forms of “dizziness”, results from disturbance somewhere in the equilibratory apparatus: vestibule, semicircular canals, 8th nerve, vestibular nuclei in the brainstem and their temporal lobe connections, or eyes” [4].

These citations show the actuality of the problem from one side and the descriptive manner of approach – from the other. There are no instrumental proofs for this or that type of dizziness. Recently, Claussen has made the important steps to objectivization and quantification of dizziness-vertigo problem [1]. Therefore, the problem of this presentation being identification of types of dizziness and studies of correlations with objective findings.

Material and methods. The data of 849 patients has been studied with average age of 41.53±12.48 y.o. Most of patients have complained of dizziness, vertigo and related symptoms, which have been studied thoroughly. They have been also examined with clinical coordination tests, ECG with neurological loading tests, vestibular evoked potentials, craniocorpography (“Galaktika”, Ukraine), videonystagmography, posturography, pendular and rotation tests, smooth pursuit and random saccades at the vestibular laboratory devices from “Micromedical Technologies, Inc.” (USA). These patients being of age 52.23±14.05 y.o.

Results. In 849 patients among other complaints more frequently then 10 % appeared to be: dizziness, subjective vertigo, objective vertigo, giddiness (pseudovertigo), disequilibrium, orthostatics, kinetosis, acrophobia, agoraphobia, nictophobia, claustrophobia, ascendophobia, descendophobia, optokinesis, nausea, vomiting, headache, black-outs, tinnitus and numbness. The entire ‘phobia’ named being at the level of mild discomfort and not the exaggerated psychiatric signs. No one patient have psychiatric diagnosis.

In 35 patients we have studied the correlation coefficients (in brackets) of complaints named versus instrumental examination results. Correlation coefficients more then 0.40 have been estimated to be significant. The next data have been obtained.

Dizziness – distortion of perception of space, movement and time. Posturography: negative correlation with limit of stability to the left (-0.4172). Pendular test (vestibulo-ocular reflex, VOR) with visual fixation suppression (VFX) at 0.04 Hz frequency: negative correlation with phase shift (-0.4754), random saccades: negative correlation with accuracy (-0.4016), smooth pursuit: positive correlation with right eye gain at 0.2 Hz (0.4101), pupillometry – positive correlation with anisocoria during Takahashi test (0.5329).

Objective vertigo – sensation the subjects moving around the patient. 20-point scale – negative correlation with the results of tracking test visual evaluation (-0.4039), posturography – negative correlation with stability limit backwards (-0.4661), VFX at 0.04 Hz – exaggerated positive correlation with asymmetry (0.74742) and phase shift (0.8570), rotatory test clockwise (CW) – asymmetrical correlation with time constant (TC) of postrotatory nystagmus (AN) (0.5495).

Subjective vertigo – illusion of nonexistent movement, patient fill him moving. VOR: positive correlation with gain at frequencies 0.08 (0.4042) and 0.16 Hz (0.4251), asymmetry of gain at counter clockwise (CCW) rotation (-0.4914).

Giddiness – vertigo which is not similar to subjective or objective ones, sometimes called pseudovertigo: very intensive, difficult to describe, patients often tell that something is rotating inside of the head. Negative correlation with height (-0,4522). Positive correlation with complaints of nausea while headache spell (0,6455). Pendular test with gaze fixation at frequency of 0,04 Hz – negative correlation with asymmetry (-0,4760) and phaze (-0,6848). Rotation test: positive correlation with time constant of nystagmus at CW rotation (0,5469).

Imbalance (movement coordination disturbance) – sometimes is met alone. Patients are complaining of swaying, staggering, momentary push… It correlates with complaints of acrophobia (0.4328) and descendophobia (0.4995). Positive correlation with the result of 20-point scale is present (0.4311). During VOR it positively correlates with gain asymmetry at 0.01 Hz (0.5862), and during VFX at 0.04 Hz has highly expressed correlation with gain asymmetry (0.7811) and especially with phase shift (0.9081).

Orthostatics – discomfort sensations which appear after sudden standing up. It correlates also with complaining of nausea (0.4267). Positive correlation with rotatory nystagmus gain (0.4531) and per-rotatory nystagmus gain (0.5290), negative with gain asymmetry (-0.4536 and -0.6916 correspondingly) and TC during CCW rotation (-0.4697). Positive correlation exists with gain during stepwise rotation both CW (0.4531), and CCW (0.52909).

Kinetosis – a disorder caused by repetitive angular and linear acceleration and deceleration and characterized primarily by nausea and vomiting [4]. It appeared to correlate with weight increase (0.4146) and photophobia in migraine attacks (0.4414). Posturography: positive correlation with limit of stability to the left test (0.5933). VOR: positive correlation with gain at 0.16 Hz (0.4549), with VFX at 0.04 Hz – positive correlation with gain (0.4474) and asymmetry (0.4028). During rotation test – negative correlation with gain CW (-0.4588) and TC CCW (-0.4893), positive correlation with asymmetry during CCW rotation (0.4221), and negative correlation with postrotational nystagmus gain CW (-0.4588).

Acrophobia (height vertigo, not belong to true vertigo) – discomfort which appears at height. Has positive correlation with imbalance (0.4328). Posturography – positive correlation with visual perturbed unstable platform test data (0.4109). During rotation test positive correlation with gain CW (0.4304) and gain of post-rotatory nystagmus (0.4304) is recorded.

Agoraphobia – (αγωρα – Grecian, market) discomfort in open, public places or crowds. Correlates positively with ascendophobia (0.4588) and associated headaches (0.4588). During VOR positive correlation is found with asymmetry at 0.64 Hz (0.4038), and during VFX at 0.04 Hz – negative correlation with asymmetry (-0.7026) and phase shift (-0.5288). During rotation test positive correlation is noted with asymmetry CW (0.4243) and TC for rotatory (0.6366) and post-rotatory nystagmus (0.4736). Pupillometry: positive correlation with anisocoria in dyadochokinesis test (0.4385).

Nictophobia – discomfort, insureness in darkness and twilights. VOR– positive correlation with phase shift at 0.32 Hz (0.5794) is found, during video vestibulo-ocular reflex (VVOR) positive correlation with asymmetry at 0.16 Hz (0.4048) being seen. While CCW rotation is negative correlation with gain it appears (-0.4144). Smooth pursuit: negative correlation with left eye gain at 0.1 (-0.4034) and 0.4 Hz (-0.4084) is noted and positive correlation with left eye asymmetry at 0.1 (0.4548) and 0.4 Hz (0.4521), and expressed positive correlation with right eye asymmetry at 0.1 (0.6678) and 0.4 Hz (0.5277) is seen.

Claustrophobia – discomfort appearing in small, closed spaces. Posturography: negative correlation with body movement velocity at the stable platform with eyes opened is recorded (-0.4581). VOR: positive correlation with asymmetry of nystagmus gain (0.4094) and phase shift (-0.600) is noted at 0.01 Hz frequency, while VFX at 0.04 Hz – underlined positive correlation with asymmetry (0.7474) and phase shift (0.8570) is recorded. During stepwise velocity rotation test negative correlation with gain CCW (-0.4376), during CW rotation positive correlation with asymmetry (0.5947) and negative correlation with TC (-0.6785) are found. Pupillometry has revealed correlation with anisocoria in Takahashi test (-0.4825).

Ascendophobia – discomfort while moving upstairs, patients note the necessity for visual control. Among other complaints correlations with agoraphobia (0.4588) and descendophobia (0.5784) are reported. 20-point scale: positive correlation with writing Fukuda test (0.4071) and general score (0.4678) is found. VOR: positive correlation with asymmetry at 0.08 Hz (0.4308) is found, as well as positive correlation with TC (0.6320) in CW rotation.

Descendophobia – discomfort during walking down the hill or descending the staircase, patients note the necessity of visual control. Among other signs there is positive correlation with age (0.4037), imbalance (0.5000), ascendophobia (0.5784) and dyspnoe (0.4461). VOR: positive correlation with asymmetry at 0.01 (0.4638), 0.04 (0.4352) and 0.08 Hz (0.4920) is visible. Step velocity CW rotation test reveals positive correlation with TC (0.7105). Random saccades have shown negative correlation with right eye right side direction movement accuracy (-0.4865).

Optokinesis – discomfort evoked by optokinetic stimuli, train or cars movement, sunrays blinking through the row of trees etc. It has positive correlation with increase of systolic (0.5202) and diastolic (0.5033) blood pressure. VOR: negative correlation with gain at 0.64 Hz frequency (-0.4002) and positive correlation with asymmetry at 0.04 (0.4223) and 0.08 Hz (0.6080). During rotation test positive correlation is found with TC CW rotation (0.4841).

Nausea is identified as urge to vomit. It has positive correlation with complaints of orthostatics (0.4267), vomiting episodes (0.4148), and dyspnoe attacks (0.4148). VOR: positive correlation with asymmetry at 0.01 Hz (0.4702), and negative at 0.08 Hz (-0.4141), as well as positive correlation with phase shift at 0.64 Hz (0.4115), during VFX test exaggerated negative correlation with asymmetry (-0.8788) and phase shift (-0.6550) at the frequency of 0.04 Hz are revealed. Rotation test envisaged positive correlation with gain both CCW (0.4594), and CW (0.4815), and negative correlation with nystagmus gain asymmetry during CCW rotation (-0.6031). Negative correlation with the increase of systolic blood pressure is reported in these patients (-0.411).

Vomiting – is forceful expulsion of gastric contents. It has positive correlation with nausea (0.4148). 20-point coordination scale: positive coordination with Uemura test results (0.4266). Pupillometry: negative correlation with anisocoria during calculation-test (-0.5363).

Headache as a substitute of dizziness is positively correlating with agoraphobia (0.4588). Posturography has revealed positive correlation with backward limit of stability test (0.4534). VOR: positive correlation of asymmetry at frequencies of 0.01 (0.4675) and 0.64 Hz (0.4786).

Black-out might appear during sudden movements of head, physical loadings or per se. During random saccades test positive correlation is revealed with velocity of the left eye movements leftward (0.5514).

Tinnitus as dizziness substitute has positive correlation with numbness (0.4462). During CCW rotation negative correlation is found with nystagmus gain (-0.4397), and positive with asymmetry of this gain (0.5069), as well as with TC of CW rotation (0.4320). Random saccades demonstrate positive correlation with the accuracy of the left eye movements leftward (0.4838).

Numbness is unpleasant sensation of temporary loss of feeling and volunteer control of the parts of the body. Among other complaints it correlates with tinnitus (0.4462). VVOR has revealed positive correlation with phase shift (0.4245), while rotation test – correlation with TC of nystagmus adaptation during CW rotation (0.4502).

Discussion. Existing in the literature classifications of dizziness types mostly have been based at subjective estimations of doctor of subjective sensations of patient [3]. This situation resulted in subjectivism in therapeutical approach to antivertiginous treatment, when in the instructions to most antivertiginous medications one might see indications like ‘dizziness of different genesis’.

Authors have noted: «Ironically, many medications used to treat dizziness list dizziness as a common side effect» [2]. The first success seems to be recognized is instrumentally proved differentiation of vertigo and dizziness, argumented by anatomic and physiologic specifics of each symptom formation [5]. One patient might complain of several types of dizziness, the amount of combinations reaching 2,43 x 1018! We have also seen that different types of dizziness have different generation area in the brain [6].

For example, objective vertigo is related to activation of parasympatic nuclei of rhomboid fosse, disinhibition of cerebellar saccade and nystagmus generators, while subjective vertigo – activation of medial longitudinal fasciculus nuclei; unilateral activation of the nuclei of rhomboid fosse, inhibition of lamina quadrigemina nuclei. In our preliminary research it has been shown that, for example Tanakan, has been effective at dizzy patients, decreasing their amount from 72,95% to 20,48 % patients. And especially effective Tanakan appeared in the cases of patients, complaining of claustrophobia – amount of patients decreased from 28,98% before treatment to 2,04% after therapy, and orthostatic attacks (before treatment 15,94%) disappeared totally after treatment.

Nootropil appeared to have strong positive effect in the patients with imbalance (coordination disturbances) accompanied with drop attacks in our preliminary studies. Medications with sedative effect – calcium channel blockers – are more effective in the cases of vertigo and much less in dizzy patients. At the same time while monitoring 19 patients treated with calcium blocker Cyclandelate, acrophobia has been revealed before treatment in 26,09% patients, after the treatment it has disappeared totally.

Betahistine in 80,85 % out of 47 patients after one month of treatment has totally eliminated severe migraine attacks accompanied with pseudovertigo. Resuming abovementioned one might see that dizziness might be clear-cut identified. Moreover, different types of dizziness are documented with different packs of instrumental examination parameters. The approach provides the hope for individualization of therapy of patients with different types of dizziness.

Conclusion. Instrumental examination has identified 20 types of dizziness with different generation levels in CNS. The approach is promising for differentiation of individual therapeutic procedures.

Literature
1. Claussen CF., Franz B. Contemporary & practical neurootology. Solvay, Hannover, 2006, 410p.
2. Desmond AL. Vestibular function: evaluation and treatment. Thieme, New York, Stuttgart, 2004, 228p.
3. Kventon JF. Symptoms of vestibular disease. In: Neurotology (Jackler RK & Brackman DE, eds.), Mosby, St.Louis, Baltimore, Boston, 1994, 145-152.
4. The Merck manual of diagnostics and therapy (Berkow R. ed-in-chief). Merck & Co Inc., Rahway, 1992, 2844p.
5. Trinus KF., Claussen CF., Barasii SM. Vertigo and dizziness: differential diagnostics and individual treatment procedures. Neurootology Newsletter, 2008, Vol. 8, №2, 6-15.
6. Trinus KF. Dizziness and related symptoms. E-handbook for postgraduate medical education. Kyiv, LITA Corp., 2010, 677p.