Post-traumatic Vertigo - Causes, Symptoms, Diagnosis, and Treatment

Introduction:

People with traumatic brain injury (TBI) or head trauma often complain of dizziness and vertigo. Sometimes, these symptoms resolve within a week without any specific treatment. Still, in some cases, these symptoms stay for longer periods, becoming more severe and affecting daily activities or work functions. The vertigo episodes following the trauma to the head are mainly due to structural or functional damage to the central nervous system (CNS). A person with post-traumatic vertigo has intermittent episodes of dizziness or vertigo, which may last for a few minutes.

What Are Dizziness and Vertigo?

Vertigo, a balance disorder, causes a false sensation of movement, often described as the room spinning. It results from inner ear issues disrupting signals to the brain from the vestibular system, which is vital for balance. Head or neck injuries can impair this system, leading to symptoms like dizziness and nausea. Post-traumatic vertigo, unique to each case, is frequently linked to benign paroxysmal positional vertigo, where trauma dislodges ear canal debris, causing vertigo sensations.

What Is the Pathophysiology of Post-traumatic Vertigo?

Blunt trauma to the head and neck region can jeopardize the entire vestibular system. Studies using radiology and postmortem analysis reveal that the specific mechanisms behind these varied vestibular injuries are occasionally ambiguous.

• Benign Paroxysmal Positional Vertigo: Among the pathophysiological mechanisms of post-traumatic vertigo, traumatic BPPV is the most comprehensively understood. Its underlying mechanisms mirror those of idiopathic BPPV, with both theories of canalithiasis and cupulolithiasis being applicable. Canalithiasis involves free-floating particles within the semicircular canal, while cupulolithiasis entails particles adhering to the cupula.

• Brainstem Concussion or Eighth Nerve Complex Injury: Even mild trauma poses a risk of injury to the eighth nerve complex due to the shearing effect on the nerve's entry zone into the brainstem. Experimental models and autopsy findings have demonstrated this mechanism.

What Are the Causes of Post-traumatic Vertigo?

Several causes of post-traumatic vertigo are:

• Road traffic accidents result in severe head injuries.

• Sports injuries or accidental falls.

• After neurosurgery (trauma during surgery of the brain).

What Are the Signs and Symptoms of Post-traumatic Vertigo?

• Nausea and vomiting.

• Frequent headaches.

• Motion sickness.

• Loss of balance.

• Uncontrolled ocular reflex or nystagmus.

• Blurred vision.

• Lightheadedness.

• Ringing sensation in the ear or tinnitus.

• Sudden blackouts.

• Mental disorientation.

• Lack of coordination.

How Is Post-traumatic Vertigo Diagnosed?

If vertigo occurs due to recent trauma, an immediate head computed tomography scan and MRI is preferred by the doctor. Various diagnostic criterias for vertigo are:

• Clinical Examination and History: A complete history of the past or recent head trauma should be noted, and past surgical history should be recorded. Clinical examination of external injuries like injury to the ears or bleeding from the ears, ear canal, and eardrum is done by an otolaryngologist.

• Neurological Test: The doctor performs some hearing and neuro-sensory tests to identify if the vertigo is due to the central origin, and the patient is referred to a neurosurgeon for further management.

• HINTS (Head Impulse Nystagmus Skew) Test: This test confirms whether the vertigo is due to a peripheral cause or a central affecting the brain stem. The patient is asked to look straight at the examiner's nose in this test. The examiner quickly thrust the patient's head to one side to 30 degrees and checked for rapid eye movement (catch-up saccade) simultaneously. If the catch-up saccade is on one side, it confirms vertigo is due to peripheral vestibular dysfunction. The presence of skew deviation (one eye is higher than the other) confirms the vertigo is due to central origin.

• Magnetic Resonance Imaging (MRI): Magnetic resonance imaging of the brain is done to check for damage to the nerves connecting the inner ears to the brain. It helps to evaluate the severity and extent of the trauma.

• Rotary Chair Testing: This test is used to confirm whether the vertigo episodes are of peripheral or central origin. In this test, a chair that is computerized is used. The patient is made to sit on the chair, and the chair is rotated slowly. Eye movements of the patient with head rotation are recorded.

• Angiogram: This is done to detect any occlusion or compression of the vertebrobasilar artery resulting in vertigo symptoms.

• Dix-Hallpike Maneuver: If BPPV (Benign Paroxysmal Positional Vertigo) is confirmed by the Dix-Hallpike maneuver or roll maneuver, then the proper repositioning maneuver should be done like Epley's maneuver or Gufoni maneuver. Before performing any maneuver, the doctor should confirm that there is no spinal cord injury. If Central causes are found, then they should be treated accordingly. If peripheral vertigo remains persistent, then a short course of corticosteroids can be taken.

• Ocular (Eye) Reflex Testing: It is done by keeping an object in front of the patient's eyes, and then the object is moved in different directions, and the movement of the eyes with the object movement is recorded simultaneously.

What Is the Treatment of Post-traumatic Vertigo?

Vertigo persisting for more than weeks needs immediate attention and early intervention.

Treatment modalities of post-traumatic vertigo are:

• Identifying the Underlying Causes: The most significant step before starting any management protocols is to first identify and confirm whether the post-traumatic vertigo attacks are of peripheral or central origin.

• Check Intracranial Pressure (ICP): If the patient is getting more serious intracranial pressure should be monitored, and drugs like Mannitol are given to reduce the pressure.

• Surgical Decompression: If all the conservative and drug therapy fails to resolve the problem, surgical decompression or craniotomy surgery is performed by the neurosurgeon to treat the underlying edema, arterial occlusion, and hemorrhage

How to Prevent Vertigo Episodes?

Episodes of vertigo can be stopped by :

• Sit and relax as soon as one feel giddy.

• Avoid standing suddenly from the bed or chair. Take time to stand from a sitting or lie-down position to avoid sudden posture changes.

• Avoid excursive head movements.

• Avoid strenuous head rotations exercises.

• Try to keep the head elevated while sleeping by using two pillows.

• Drink plenty of water.

Conclusion:

Vertigo can occur spontaneously to anyone. Vertigo or recurrent dizziness episodes drastically affect the ability of a person to balance, concentrate, and perform daily life activities. Mostly, the symptoms of vertigo subside within a week. Symptoms of vertigo that persist more than weeks after the head injury or any other neurological lesions are serious complications indicating structural or functional damage to the brainstem that needs to be reported to a doctor immediately. Early diagnosis and management of post-traumatic vertigo are crucial to prevent further complications and manage them effectively.