V E R T I G

O
dr. Kiki Mohammad Iqbal, SpS
Departemen Neurologi
FK USU / RSUP H. ADAM MALIK MEDAN
1

PENDAH ULUAN
Balance results from a complex interaction of
sensory information from several sources :
1) Vestibular system (labiryinth)
sensory hair cells within
the inner ear monitor the
position and motion of the
head in the environment

PENDAH ULUAN
Balance results from a complex interaction of
sensory information from several sources :
2) The eye visual
cues are important in
maintaining balance
and oculomotor
control
3

PENDAH ULUAN
Balance results from a complex interaction of
sensory information from several sources :
3) Proprioceptive :
a) Skin pressure receptors provide
information about which part of the
body is in contact with the ground

PENDAH ULUAN
Balance results from a complex interaction of
sensory information from several sources :
3) Proprioceptive :
b) Muscle and joint sensory
receptors provide information
on the position of the limbs in
the environment
5

PENDAH ULUAN
Balance results from a complex interaction of
sensory information from several sources :

TIN GK AT R ESEPSI
6

PENDAH ULUAN
Sensory information from all relevant
sources is processed in the CNS
specifically the brain stem and cerebellum
TIN GK AT INTEGR ASI

PENDAH ULUAN
Sensory information from all relevant
sources is processed in the CNS
specifically the brain stem and cerebellum
with additional input from the cerebral
cortex
TINGKAT PERSEPSI

PENDAH ULUAN
The output from this processing controls
motor responses relating to eye movement,
postural control and perceptual output
allowing the body to navigate in the
environment

Controls
eye
movements

Postural
control via
muscles

Balance

PENDAH ULUAN
Contradictory or missing information from any
of the sensory systems, or an impairment of the
central processing of information

dizziness /
imbalance
Controls
eye
movements

dysfunction

Postural
control via
muscles

Balance

10

KLASIFIKASI DIZZINESS
TIPE

SENSASI

SISTEM

Spinning

Vestibuler

Light
headed

Visual

1) Vertigo :
a. Vertigo Vestibuler
b. Vertigo Non
Vestibuler

Proprioseptif
2) Presyncope
3) Dysequilibrium

Fainting

Kardiovaskular

Falling

Serebellar

Unsteady

Spinal
11

DEFINISI VERTIGO
Vertigo suatu bentuk gangguan
orientasi ruangan di mana dpt bersifat :
vertigo subjektif perasaan dirinya
bergerak thd ruangan sekitarnya
vertigo objektif ruangan sekitarnya
bergerak thd dirinya
Prevalensi vertigo sekitar 47%
Populasi usia > 75 thn prevalensi 13-38%
12

KONFIRMASI VERTIGO

Vertigo suatu gejala subjektif

Istilah yg digunakan penderita berbeda
Pusing, puyeng, oyong, melayang, dsb
Minta penderita utk menguraikan apa yg
dirasakan pada saat serangan vertigo
rasa berputar, rasa tertarik ke bumi,
melayang, penglihatan bergoyang, dsb
13

KLASIFIKASI VERTIGO
VERTIGO VESTIBULAR

VERTIGO NON VESTIBULAR

Rasa Berputar

Rasa Melayang, Goyang,

Sempoyongan

Sifat Serangan

Episodik

Kontinu

Mual / muntah

(+)

(-)

Ggn
Pendengaran

(+) / (-)

(-)

Gerakan
Pencetus

Gerakan Kepala

Gerakan Objek Visual

(-)

Ramai orang, lalu lintas,

macet, sibuk, pasar,
swalayan

Sistem Vestibular

Sistem Visual,
Somatosensorik

Sifat Vertigo

Situasi
Pencetus
Letak Lesi

14

KLASIFIKASI VERTIGO
VERTIGO VESTIBULAR

Bangkitan Vertigo
Intensitas
Pengaruh Gerakan
Kepala
Gejala Otonom
Gangguan
Pendengaran
Tanda Fokal Otak

PERIFER

SENTRAL

Mendadak

Lebih Lambat

Berat

Ringan

(+)

(-)

(++)

()

(+)

(-)

(-)

(+)
15

ANATOMI SISTEM VESTIBULAR

SENTRAL

PERIFER

16
16

ANATOMI SISTEM VESTIBULAR

PERIFER :

End organ vestibuler :

kanalis semisirkularis
utrikulus
sakulus
saccu-endolimpatikus

Ganglia vestibularis

Scarpey
Nervus vestibularis
17
17

ANATOMI SISTEM VESTIBULAR

SENTRAL :

Nukleus vestibularis

di medulla oblongata
Serebelum dan
Connecting Central
Pathway

18

ETIOLOGI VERTIGO

19

ETIOLOGI VERTIGO
OTOLOGIC VERTIGO :

BPPV
Menieres Disease
Vestibular Neuritis
Labyrinthitis
Bilateral Vestibular Parese
Perilymph Fistula
Trauma
Tumors compressing N.VIII
Obat-obatan
20

ETIOLOGI VERTIGO
CENTRAL VERTIGO :

Stroke dan TIA (VB Insuf)

Basilar Artery Migraine
Seizures
Multiple Sclerosis
Chiari Malformation
21

ETIOLOGI VERTIGO
NON VESTIBULAR VERTIGO :
Polyneuropathy Cervical Trauma
Myelopathy Arthritis Cervicalis
Multisensory Deficit

MEDICAL / SYSTEMIC
VERTIGO :

Postural Hypotension
Cardiac Arrhytmia
Hypoglicemia and DM
Medication Effects
Viral Syndrome

UNLOCALIZED
VERTIGO SYNDROMES

Anxiety and Panic

Posttraumatic Vertigo
Hyperventilation
Malingering
Unknown
22

BPPV is the most common cause of Vertigo

% patients per 100 cases

Survey of 625 ENT specialists in France

Cause of vertiginous symptoms

Toupet M et al. Rev SFORL 2004;83:5763.

23

BPPV
Benign Paroxysmal Positional Vertigo
Karakteristik :
serangan vertigo perifer
berulang dan singkat
berhubungan dgn perubahan posisi
kepala dari tidur melihat ke atas
kemudian memutar kepala
24

BPPV
Prevalensi 2,4% meningkat sesuai usia
Wanita >> laki-laki untuk semua umur
Etiologi :
Idiopatik 50%
simptomatik : pasca trauma, pasca
labirintitis, pasca operasi, dll
Prognosis : kambuh 40-50% dalam 5 thn
25

BPPV
Patofisologi :
Makula dalam utrikulus diduga
merupakan sumber partikel kalsium
menyebabkan BPPV
Partikel kalsium karbonat (otokonia)
memiliki densitas 2x lipat dr endolimf
berespons thd perubahan
gravitasi & gerakan akselerasi lain
26

DIAGNOSIS VERTIGO
Diagnosis jenis vertigo, lesi anatomis, dan
penyebab nya ditegakkan berdasarkan :
1) Anamnese :

Bentuk serangan
Sifat serangan dan intensitas
Keadaan yang memprovokasi
Gangguan otonom, ggn pendengaran
Penggunaan obat, penyakit sistemik
27

DIAGNOSIS VERTIGO
Apakah anda terasa mau pingsan ? (Pingsan /
fainting) PRESYNCOPE
Apakah anda merasa kedua tungkai tidak stabil,
dan menjadi stabil kalau duduk ? ( Jatuh / falling)
DYSEQUILIBRIUM
Apakah lingkungan anda kelihatannya berputar,
atau anda sendiri terasa berputar ? ( Berputar /
spinning) VERTIGO VESTIBULAR
Apakah merasa lingkungan bergoyang, atau anda
sendiri terasa bergoyang ? (Melayang / lightheaded) VERTIGO NON VESTIBULAR
28

DIAGNOSIS VERTIGO
Diagnosis jenis vertigo, lesi anatomis, dan
penyebab nya ditegakkan berdasarkan :
2) Pemeriksaan fisik / neurologis :
a) Fungsi vestibuler / serebelum :
Romberg test
Past-pointing test
Head-shaking test

Tandem Gait test

Fukuda test

b) Saraf kranialis
c) Fungsi motorik dan sensorik
29

DIAGNOSIS VERTIGO
Diagnosis jenis vertigo, lesi anatomis, dan
penyebab nya ditegakkan berdasarkan :
3) Pemeriksaan khusus neuro otologi :
a)
b)
c)
d)
e)

Nylen Barani atau Dix Hallpike test

Test kalori
Elektronistagmografi (ENG)
Audiometri
Brainstem Auditory Evoked Potential (BAEP)
30

DIAGNOSIS VERTIGO
Diagnosis jenis vertigo, lesi anatomis, dan
penyebab nya ditegakkan berdasarkan :
4) Pemeriksaan penunjang :
a) Laboratorium, EKG
b) EEG, EMG
c) Neuroimaging

31

DIX-HALLPIKE TEST
Kepala menengok
30-45 ke sisi kiri /
kanan, menatap
dahi
pemeriksa,
perhatikan adanya
nistagmus spontan
32

DIX-HALLPIKE TEST
Kepala pasien
dipegang, lalu
tubuh dibaringkan
dengan cepat sampai
kepala menggantung
15-30 di bawah
garis horisontal
nistagmus 10-15
33

DIX-HALLPIKE TEST
Setelah itu pasien
dikembalikan ke
posisi duduk
dengan cepat,
perhatikan adanya
nistagmus selama
10-15
34

DIX-HALLPIKE TEST
Hal yang sama
dilakukan kembali
pada sisi yang lain
nistagmus
posisional dapat
membedakan
kelainan perifer atau
sentral
35

NISTAGMUS POSISIONAL
Nistagmus Posisional
Perifer

Sentral

Latensi

(+) 2-20 dtk

(-)

Fatique

(+)

(-)

Vertigo

(+)

(+ / -)

Ke telinga bawah

Ke telinga atas /
bervariasi

< 1 menit

> 1 menit

Arah Nistagmus
Lamanya

36

DIAGNOSA BANDING
DURASI EPISODE VERTIGO
Detik :

Menit s/d Jam :

Sehari lebih :

BPPV

Menieres disease

Vestibular neuritis

Perilymph fistula

Multiple sclerosis
Ischaemia impacting
on the brain stem

Migraine
Transient ischemic attack

37

P E N A TA L A K S A N A A N
Effective management requires identification of

vertigo type and cause.

Aim of treatment :
1. Treat the underlying cause :
Pharmacotherapy
Particle repositioning procedure
Surgery
2. Manage symptoms :
Pharmacotherapy
3. Promote long-lasting neural reorganisation :
Vestibular rehabilitation exercises
38

P E N A TA L A K S A N A A N
TIPE VERTIGO

PENGOBATAN

PERIFER :
BPPV

Canalith repositioning manoeuvre

Labyrinthine concussion

Vestibular rehabilitation

Menieres disease

Low-salt diet, diuretic, surgery, transtympanic gentamicin

Labyrinthitis

Antibiotics, removal of infected tissue, vestibular rehabilitation

Perilymph fistula

Bed rest, avoidance of straining

Vestibular neuritis

Brief course of high-dose steroids, vestibular rehabilitation

SENTRAL :
Migraine

Beta-blockers, calcium channel blockers, tricyclic amines

Vascular disease

Control of vascular risk factors, e.g., antiplatelet agents

Cerebellopontine tumours

Surgery
39

P E N A TA L A K S A N A A N
TERAPI SIMPTOMATIK VERTIGO :

SUPRESAN
VESTIBULAR

ANTI EMETIKUM

40

P E N A TA L A K S A N A A N
TERAPI SIMPTOMATIK VERTIGO :
1) Supresan vestibular :
a) Antihistamin
antikholinergik :
Dimenhydrinate
50 mg/4-6 jam

Diphenhydramine
Meclizine
12,5-50 mg/4-6 jam

b) Benzodiazepine :
Lorazepam
0,5 mg 2x sehari

Diazepam
2 mg 2x sehari

Clonazepam
0,5 mg 2x sehari

TC and Yacovino D. Pharmacologic Treatment for Persons with Dizziness. Neurol Clin 2005;23:831-853

41

P E N A TA L A K S A N A A N
TERAPI SIMPTOMATIK VERTIGO :
1) Supresan vestibular :
c) Calcium channel
blocker :
Flunarizine
10 mg 1x sehari

Cinnarizine

d) Obat lainnya :
Betahistine
Ginkgo biloba
Baclofen
Amantadine

25 mg 3x sehari

TC and Yacovino D. Pharmacologic Treatment for Persons with Dizziness. Neurol Clin 2005;23:831-853

42

P E N A TA L A K S A N A A N
TERAPI SIMPTOMATIK VERTIGO :
2) Anti emetikum :
a) Phenothiazine :
Prochlorperazine (5-10 mg tiap 6-8 jam)
Promethazine (25 mg tiap 6-8 jam)
b) Metoclopramide (10 mg 3x sehari)
c) Domperidone
d) Sulpiride
e) Ondansetron (4-8 mg 3x sehari)
TC and Yacovino D. Pharmacologic Treatment for Persons with Dizziness. Neurol Clin 2005;23:831-853

43

P E N A TA L A K S A N A A N
MANUVER EPLEY

44

P E N A TA L A K S A N A A N
LATIHAN BRAND-DAROFF

45

ALGORITMA VERTIGO
1. Konfirmasi
Vertigo ?
Vertigo Vestibular

2. Tentukan Jenis

Perife
r

3. Tentukan Letak
Lesi

Sentr
al

4. Cari Kausa

Vertigo Non
Vestibular
Visual

Somatosenso
rik
(Proprioseptif
)

5. Pilih Terapi :
Kausal
Simtomatik
Rehabilitasi

46

TE R IM A K AS IH

47