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Chapter 22. Dizziness, Imbalance, and Vestibular Dysfunction

Maura K. Cosetti, M.D.; Anil K. Lalwani, M.D.
DOI: 10.1176/appi.books.9781585624201.681032

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Excerpt

Since the 1940s, dizziness, vertigo, and imbalance have been well documented and commonly reported sequelae of traumatic brain injury (TBI) (Maskell et al. 2006). While long recognized, the complex relationship between dizziness and TBI remains incompletely understood. "Dizziness" in itself is a nonspecific term that may encompass a wide variety of symptoms, including vertigo, imbalance, disequilibrium, light-headedness, altered coordination, and disorientation. Entangled and often inseparable, these symptoms represent a complex continuum of sequelae that cross vestibular, cognitive, and psychosocial domains. This broad spectrum of symptomatology gives some insight into the diversity of pathology present in the TBI patient. It is both the diversity and complexity of injuries that pose unique diagnostic and treatment challenges to the clinician.

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Figure 22–1. Anatomy and physiology of the vestibular system.A. The peripheral auditory and vestibular systems are composed of the external ear, including the auricle and external auditory canal (EAC); the middle ear, including the tympanic membrane (TM) and three ossicles, specifically the malleus (M), incus (I), and stapes (S); and the inner ear, composed of the cochlea and the three semicircular canals (SC) of the vestibular apparatus, specifically the lateral (Lat SC), superior (Sup SC), and posterior (Post SC).B. Focused view of the dilated, or ampullated, end of a semicircular canal showing the cristae ampullaris, neuroepithelium (including the hair cells), and the cupula. Fluid motion, generated by head rotation, generates forces across the cupula that bend the stereocilia of the hair cells, resulting in release of neurotransmitter into the vestibular synapse.C. Focused view of vestibular hair cells within the ampulla. Each hair cell has approximately 70 short stereocilia and one longer kinocilium that project into the gelatinous cupula. It is the laterally located kinocilium that is the primary determinant of the direction of polarization. Each hair cell is innervated by vestibular afferent neurons that allow transmission of positional information to the brain.

Figure 22–2. Vestibular ocular reflex.Connections among the vestibular, abducens, and oculomotor nuclei allow maintenance of vision during head movement. Rotational head movement yields both excitatory and inhibitory peripheral signals depending on the direction of motion. In this example, maintenance of an image on the retina during head rotation to the right requires conjugate leftward gaze. This is accomplished by stimulation of the right lateral semicircular canal and subsequent activation of the vestibular, abducens, and oculomotor nuclei. Ultimately, this neural circuitry culminates in activation of the left lateral and right medial rectus muscles and inhibition of left medial and right lateral recti. Integration of these signals takes place directly in the medial longitudinal fasciculus and indirectly in the pontine reticular formation (not shown).
Table Reference Number
Table 22–1. Vestibular history taking: questions to assist in diagnosis
Table Reference Number
Table 22–2. Diagnostic testing and application to TBI

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