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Test Your Knowledge of Vestibular Disorders
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Test Your Knowledge of Vestibular Disorders

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Questions and Answers

What is the most common cause of positional vertigo?

  • Vestibular neuritis
  • Chronic dizziness
  • Benign paroxysmal positional vertigo (BPPV) (correct)
  • Cervical vertigo

    • What is the first pivotal step in evaluating patients with dizziness?

  • Distinguishing between the three major symptoms associated with dizziness (correct)
  • Performing a Roll test
  • Conducting a detailed history and clinical examination
  • Looking for clues on history and neurological examination associated with CNS disease

    • What is the most effective treatment for posterior canal BPPV?

  • Antihistamines and anticholinergic drugs
  • Physiotherapy
  • The Epley maneuver (correct)
  • Vestibular rehabilitation

    • What is the mainstay for the management of vestibular migraine?

    <p>Prophylactic medications</p> Signup and view all the answers

    What is the age range of people most commonly affected by vestibular neuritis?

    <p>40-50</p> Signup and view all the answers

    What is the most common symptom of vestibular neuritis?

    <p>Vertigo</p> Signup and view all the answers

    What is the current diagnostic criteria for Meniere's disease?

    <p>Two or more spontaneous attacks of vertigo, low to medium frequency sensorineural hearing loss, and fluctuating aural symptoms</p> Signup and view all the answers

    What is the first-line management for Meniere's disease?

    <p>Betahistine and diuretics</p> Signup and view all the answers

    What is the most common cause of positional vertigo?

    <p>Benign paroxysmal positional vertigo (BPPV)</p> Signup and view all the answers

    What is the HINTS examination used for?

    <p>To distinguish between central and peripheral causes of vertigo</p> Signup and view all the answers

    What is the most effective treatment for posterior canal BPPV?

    <p>The Epley maneuver</p> Signup and view all the answers

    What is the first pivotal step in the evaluation of patients with dizziness?

    <p>Distinguish between the three major symptoms associated with dizziness</p> Signup and view all the answers

    What is the most common symptom of vestibular neuritis?

    <p>Vertigo</p> Signup and view all the answers

    What is the mainstay for the management of vestibular migraine?

    <p>Prophylactic medications</p> Signup and view all the answers

    What is the current diagnostic criteria for Meniere's disease?

    <p>Two or more spontaneous attacks of vertigo</p> Signup and view all the answers

    What is cervical vertigo?

    <p>A type of vertigo that originates from the cervical spine and is characterized by neck pain and stiffness</p> Signup and view all the answers

    What is the most common cause of positional vertigo?

    <p>BPPV</p> Signup and view all the answers

    What is the first pivotal step in evaluating patients with dizziness?

    <p>Distinguishing between vertigo, near syncope, and dysequilibrium</p> Signup and view all the answers

    What is the HINTS examination used for?

    <p>To distinguish between central and peripheral causes of vertigo</p> Signup and view all the answers

    What is the most effective treatment for posterior canal BPPV?

    <p>The Epley maneuver</p> Signup and view all the answers

    What is the most prevalent symptom of vestibular migraine?

    <p>Internal vertigo</p> Signup and view all the answers

    What is the second pivotal step in evaluating patients with dizziness?

    <p>Looking for clues on history and neurological examination associated with CNS disease</p> Signup and view all the answers

    What is the most common symptom of vestibular neuritis?

    <p>Vertigo</p> Signup and view all the answers

    What is the most effective treatment for chronic dizziness due to unilateral or bilateral vestibulopathy?

    <p>Vestibular rehabilitation</p> Signup and view all the answers

    What is the current diagnostic criteria for Ménière's disease?

    <p>Two or more spontaneous attacks of vertigo, low to medium frequency sensorineural hearing loss, and fluctuating aural symptoms</p> Signup and view all the answers

    What is the most effective treatment for vertigo caused by cervical dysfunction?

    <p>Manual therapy</p> Signup and view all the answers

    What is the most common category of dizziness?

    <p>Vertigo</p> Signup and view all the answers

    What is the most common cause of central vertigo?

    <p>Damage to the vestibular nuclei in the brainstem</p> Signup and view all the answers

    What is the most common cause of positional vertigo?

    <p>BPPV</p> Signup and view all the answers

    What is the second most common cause of BPPV?

    <p>Horizontal canal BPPV</p> Signup and view all the answers

    What is the most effective treatment for posterior canal BPPV?

    <p>Epley maneuver</p> Signup and view all the answers

    What is the age range of people most affected by vestibular neuritis?

    <p>40-50</p> Signup and view all the answers

    What is the first pivotal step in evaluating patients with dizziness?

    <p>Distinguishing between vertigo, near syncope, and dysequilibrium</p> Signup and view all the answers

    What is the most prevalent symptom in vestibular migraine?

    <p>Internal vertigo</p> Signup and view all the answers

    What is the current diagnostic criteria for Meniere's disease?

    <p>Two or more spontaneous attacks of vertigo</p> Signup and view all the answers

    What is the first-line management for Meniere's disease?

    <p>Betahistine and diuretics</p> Signup and view all the answers

    What is cervical vertigo?

    <p>Vertigo originating from the cervical spine</p> Signup and view all the answers

    What is the second-line management for Meniere's disease?

    <p>Intratympanic steroid injection</p> Signup and view all the answers

    What is the most effective treatment for vertigo caused by cervical dysfunction?

    <p>Manual therapy</p> Signup and view all the answers

    What is the most common symptom of vestibular neuritis?

    <p>Vertigo</p> Signup and view all the answers

    What is the most common cause of positional vertigo?

    <p>BPPV</p> Signup and view all the answers

    What is the second most common cause of BPPV?

    <p>Horizontal canal BPPV</p> Signup and view all the answers

    What is the most effective treatment for posterior canal BPPV?

    <p>Epley maneuver</p> Signup and view all the answers

    What is the age range of people most affected by vestibular neuritis?

    <p>40-50</p> Signup and view all the answers

    What is the first pivotal step in evaluating patients with dizziness?

    <p>Distinguishing between vertigo, near syncope, and dysequilibrium</p> Signup and view all the answers

    What is the most prevalent symptom in vestibular migraine?

    <p>Internal vertigo</p> Signup and view all the answers

    What is the current diagnostic criteria for Meniere's disease?

    <p>Two or more spontaneous attacks of vertigo</p> Signup and view all the answers

    What is the first-line management for Meniere's disease?

    <p>Betahistine and diuretics</p> Signup and view all the answers

    What is cervical vertigo?

    <p>Vertigo originating from the cervical spine</p> Signup and view all the answers

    What is the second-line management for Meniere's disease?

    <p>Intratympanic steroid injection</p> Signup and view all the answers

    What is the most effective treatment for vertigo caused by cervical dysfunction?

    <p>Manual therapy</p> Signup and view all the answers

    What is the most common symptom of vestibular neuritis?

    <p>Vertigo</p> Signup and view all the answers

    What is the most common cause of positional vertigo?

    <p>Benign paroxysmal positional vertigo (BPPV)</p> Signup and view all the answers

    What is the first pivotal step in evaluating patients with dizziness?

    <p>Distinguishing the three major symptoms associated with dizziness</p> Signup and view all the answers

    What is the most effective treatment for chronic dizziness due to unilateral or bilateral vestibulopathy?

    <p>Vestibular rehabilitation</p> Signup and view all the answers

    What is the most prevalent symptom of vestibular neuritis?

    <p>Vertigo</p> Signup and view all the answers

    What is the mainstay for the management of vestibular migraine?

    <p>Prophylactic medications</p> Signup and view all the answers

    What is the most common symptom of Meniere's disease?

    <p>Vertigo</p> Signup and view all the answers

    What is the second pivotal step in evaluating patients with dizziness?

    <p>Looking for clues on history and neurological examination associated with CNS disease</p> Signup and view all the answers

    What is the most effective treatment for posterior canal BPPV?

    <p>Epley maneuver</p> Signup and view all the answers

    What is the most prevalent symptom of vestibular migraine?

    <p>Internal vertigo</p> Signup and view all the answers

    What is the diagnostic criteria for Meniere's disease?

    <p>Two or more spontaneous attacks of vertigo, low to medium frequency sensorineural hearing loss, and fluctuating aural symptoms</p> Signup and view all the answers

    What is the most effective treatment for vertigo caused by cervical dysfunction?

    <p>Manual therapy</p> Signup and view all the answers

    What is the most common cause of dizziness?

    <p>All of the above</p> Signup and view all the answers

    What percentage of the population is affected by dizziness?

    <p>15-35%</p> Signup and view all the answers

    What is the first pivotal step in evaluating patients with dizziness?

    <p>Distinguishing between vertigo, near syncope, and dysequilibrium</p> Signup and view all the answers

    What is the most common cause of positional vertigo?

    <p>Benign paroxysmal positional vertigo (BPPV)</p> Signup and view all the answers

    What is the most effective treatment for posterior canal BPPV?

    <p>The Epley maneuver</p> Signup and view all the answers

    What is the most prevalent symptom of vestibular migraine?

    <p>Internal vertigo</p> Signup and view all the answers

    What is the current diagnostic criteria for Meniere's disease?

    <p>All of the above</p> Signup and view all the answers

    What is the first-line management for Meniere's disease?

    <p>Betahistine and diuretics</p> Signup and view all the answers

    What is cervical vertigo?

    <p>Vertigo that originates from the cervical spine and is characterized by neck pain and stiffness</p> Signup and view all the answers

    What is the diagnosis of cervical vertigo based on?

    <p>The symptom of neck pain</p> Signup and view all the answers

    What is the second pivotal step in evaluating patients with dizziness?

    <p>Looking for clues on history and neurological examination associated with CNS disease</p> Signup and view all the answers

    What is the most common symptom of vestibular neuritis?

    <p>Vertigo</p> Signup and view all the answers

    What is the most effective treatment for chronic dizziness due to unilateral or bilateral vestibulopathy?

    <p>Vestibular rehabilitation</p> Signup and view all the answers

    What is the most common cause of positional vertigo?

    <p>Benign paroxysmal positional vertigo (BPPV)</p> Signup and view all the answers

    Which age group is most commonly affected by vestibular neuritis?

    <p>Adults aged 30-60</p> Signup and view all the answers

    What is the first pivotal step in evaluating patients with dizziness?

    <p>Identify the three major symptoms associated with dizziness</p> Signup and view all the answers

    What is the most effective treatment for posterior canal BPPV?

    <p>The Epley maneuver</p> Signup and view all the answers

    What is the mainstay for the management of vestibular migraine?

    <p>Prophylactic medications</p> Signup and view all the answers

    What is the second pivotal step in evaluating patients with dizziness?

    <p>Look for clues on history and neurological examination associated with CNS disease</p> Signup and view all the answers

    What is the most common symptom of vestibular neuritis?

    <p>Vertigo</p> Signup and view all the answers

    What is the most effective treatment for chronic dizziness due to unilateral or bilateral vestibulopathy?

    <p>Vestibular rehabilitation</p> Signup and view all the answers

    What is the current diagnostic criteria for Meniere's disease?

    <p>Two or more spontaneous attacks of vertigo, low to medium frequency sensorineural hearing loss, and fluctuating aural symptoms</p> Signup and view all the answers

    What is the most common cause of dizziness?

    <p>Vertigo</p> Signup and view all the answers

    What is the most common cause of central vertigo?

    <p>Damage to the vestibular nuclei in the brainstem</p> Signup and view all the answers

    What is the first-line preventive management for Meniere's disease?

    <p>Lifestyle modifications</p> Signup and view all the answers

    What is the primary cause of secondary injuries in TBI patients?

    <p>Molecular and cellular pathways</p> Signup and view all the answers

    What is the most important part of Glasgow Coma Score (GCS) evaluation in deeply sedated TBI patients?

    <p>Motor response</p> Signup and view all the answers

    What is the critical threshold for cerebral perfusion pressure (CPP)?

    <p>50-60 mmHg</p> Signup and view all the answers

    Which of the following is NOT an aggressive treatment for refractory elevated intracranial pressure (ICP)?

    <p>Hypertonic saline</p> Signup and view all the answers

    What is the ischemic threshold for brain oxygenation measured by PbtO2?

    <p>10-20 mmHg</p> Signup and view all the answers

    What is the recommended target range for cerebral perfusion pressure (CPP) in the Lund concept?

    <p>50-60 mmHg</p> Signup and view all the answers

    What is the marker of ischemia and/or diffusion hypoxia measured by microdialysis?

    <p>Lactate/glucose ratio</p> Signup and view all the answers

    What is the technique that allows for online analysis of extracellular/interstitial biochemical changes in brain glucose metabolism, cell membrane degradation, and excitatory neurotransmitter levels?

    <p>Microdialysis</p> Signup and view all the answers

    What is the physiological mechanism that maintains adequate cerebral perfusion in the presence of blood pressure changes?

    <p>Autoregulation</p> Signup and view all the answers

    What is the proposed algorithm to manage abnormal SjVO2?

    <p>All of the above</p> Signup and view all the answers

    What is the last-resort treatment for severe refractory ICP?

    <p>Decompressive craniectomy</p> Signup and view all the answers

    What is the technique that measures pupil size and light reactivity, automatically improving inter-rater accuracy?

    <p>Automated pupillometry</p> Signup and view all the answers

    What is the primary cause of secondary injuries in TBI?

    <p>Molecular and cellular pathways</p> Signup and view all the answers

    What is the most important part of GCS evaluation in deeply sedated TBI patients?

    <p>Motor response</p> Signup and view all the answers

    What is the critical threshold for CPP in TBI patients?

    <p>50-60 mmHg</p> Signup and view all the answers

    What is the main goal of the specialized neurointensive approach for severe TBI patients?

    <p>Maintain cerebral homoeostasis</p> Signup and view all the answers

    What is the most effective hyperosmolar agent for reducing brain swelling in TBI patients?

    <p>Hypertonic saline</p> Signup and view all the answers

    What is the ischemic threshold for PbtO2 in TBI patients?

    <p>15-20 mmHg</p> Signup and view all the answers

    What is the main disadvantage of barbiturate coma and hypothermia for treating refractory elevated ICP in TBI patients?

    <p>All of the above</p> Signup and view all the answers

    What is the main advantage of continuous EEG monitoring in TBI patients?

    <p>Detection of electrographic seizures</p> Signup and view all the answers

    What is the main disadvantage of decompressive craniectomy for treating severe refractory ICP in TBI patients?

    <p>Increased mortality</p> Signup and view all the answers

    What is the most important factor in the Lund concept for reducing ICP in TBI patients?

    <p>Reduction of intracranial volumes</p> Signup and view all the answers

    What is the main advantage of autoregulation assessment in TBI patients?

    <p>Assessment of cerebrovascular autoregulation</p> Signup and view all the answers

    What is the main disadvantage of traditional ICP therapy in TBI patients?

    <p>All of the above</p> Signup and view all the answers

    What is the Glasgow Coma Score (GCS) used for in TBI patients?

    <p>To identify neurological deterioration</p> Signup and view all the answers

    What is the critical threshold for cerebral perfusion pressure (CPP) in TBI patients?

    <p>50-60 mmHg</p> Signup and view all the answers

    What is the Lund concept in TBI management?

    <p>A therapeutic approach that focuses on the reduction of ICP by decreasing intracranial volumes</p> Signup and view all the answers

    What is the ischemic threshold for brain oxygenation measured by PbtO2 in TBI patients?

    <p>5-20 mmHg</p> Signup and view all the answers

    What is the purpose of microdialysis in TBI patients?

    <p>To analyze extracellular/interstitial biochemical changes in brain glucose metabolism, cell membrane degradation, and excitatory neurotransmitter levels</p> Signup and view all the answers

    What is the major excitatory amino acid in the brain and a marker for neuronal oxidative metabolism under normal conditions?

    <p>Glutamate</p> Signup and view all the answers

    What is the pressure-reactivity index (PRx) used for in TBI patients?

    <p>To assess cerebrovascular autoregulation</p> Signup and view all the answers

    What is the purpose of automated pupillometry in TBI patients?

    <p>To measure pupil size and light reactivity</p> Signup and view all the answers

    What is the most effective hyperosmolar agent for reducing brain swelling in TBI patients?

    <p>Hypertonic saline</p> Signup and view all the answers

    What is the aim of a specialized neurointensive approach in TBI patients?

    <p>To prevent secondary insults, maintain cerebral homoeostasis, and preserve rehabilitation potential</p> Signup and view all the answers

    What is the purpose of a routine second CT scan within 24 hours in comatose TBI patients?

    <p>To identify neurological deterioration and potential indications for surgical interventions</p> Signup and view all the answers

    What is the main disadvantage of decompressive craniectomy as a treatment for severe refractory ICP in TBI patients?

    <p>It increases the incidence of unfavorable outcomes at six months</p> Signup and view all the answers

    What is the most important part of Glasgow Coma Score (GCS) evaluation in patients who are deeply sedated?

    <p>Motor response</p> Signup and view all the answers

    What is the critical threshold for CPP in traumatic brain injury patients?

    <p>50-60 mmHg</p> Signup and view all the answers

    Which of the following is NOT a strategy proposed for intracranial pressure (ICP) therapy in traumatic brain injury patients?

    <p>Snyder concept</p> Signup and view all the answers

    What is the ischemic threshold for PbtO2 in traumatic brain injury patients?

    <p>10-20 mmHg</p> Signup and view all the answers

    What is the main advantage of automated pupillometry in traumatic brain injury patients?

    <p>It improves inter-rater accuracy</p> Signup and view all the answers

    What is the main disadvantage of mannitol compared to hypertonic saline and Na-lactate in reducing brain swelling?

    <p>It is less effective</p> Signup and view all the answers

    What is the main disadvantage of barbiturate coma and hypothermia in treating refractory elevated intracranial pressure?

    <p>They carry risks of cardiovascular depression and infections</p> Signup and view all the answers

    What is the main advantage of the Lund concept compared to a CPP-targeted protocol in treating elevated intracranial pressure?

    <p>It emphasizes reduction of microvascular pressures</p> Signup and view all the answers

    What is the main disadvantage of decompressive craniectomy in treating severe refractory intracranial pressure?

    <p>It increases the incidence of unfavorable outcomes at six months</p> Signup and view all the answers

    What is the main purpose of autoregulation assessment in traumatic brain injury patients?

    <p>To maintain adequate cerebral perfusion in the presence of blood pressure changes</p> Signup and view all the answers

    What is the main use of microdialysis in traumatic brain injury patients?

    <p>To analyze extracellular/interstitial biochemical changes</p> Signup and view all the answers

    What is the main advantage of cerebral microdialysis in detecting seizures in traumatic brain injury patients?

    <p>It provides continuous monitoring</p> Signup and view all the answers

    What is the main goal of a neurointensive approach for patients with severe TBI?

    <p>To maintain cerebral homoeostasis and prevent secondary insults</p> Signup and view all the answers

    What is the most important part of Glasgow Coma Score evaluation in deeply sedated TBI patients?

    <p>Motor response</p> Signup and view all the answers

    What is the critical threshold for CPP in TBI patients?

    <p>Between 50 and 60 mmHg</p> Signup and view all the answers

    Which one of these is not a main strategy proposed for ICP therapy in TBI patients?

    <p>Barbiturate coma</p> Signup and view all the answers

    What is the main goal of the Lund concept therapeutic approach for TBI patients?

    <p>To reduce ICP by decreasing intracranial volumes</p> Signup and view all the answers

    What is the ischemic threshold for PbtO2 in TBI patients?

    <p>Between 5 and 20 mmHg</p> Signup and view all the answers

    What is the main advantage of automated pupillometry in TBI patients?

    <p>It measures pupil size and light reactivity</p> Signup and view all the answers

    What is the main disadvantage of mannitol compared to hypertonic saline and Na-lactate in TBI patients?

    <p>It does not improve tissue oxygenation</p> Signup and view all the answers

    What is the pressure-reactivity index (PRx) used for in TBI patients?

    <p>To assess cerebrovascular autoregulation</p> Signup and view all the answers

    What is the main disadvantage of decompressive craniectomy in TBI patients?

    <p>It increases the incidence of unfavorable outcomes at six months</p> Signup and view all the answers

    What is the main advantage of cerebral microdialysis (CMD) in TBI patients?

    <p>It allows for detection of LPR, glutamate, and glycerol increase when electrographic seizures occur</p> Signup and view all the answers

    What is the main disadvantage of barbiturate coma in TBI patients?

    <p>It carries risks of cardiovascular depression and infections</p> Signup and view all the answers

    Study Notes

    A Holistic Approach to Vertigo: A Practical Update

    • Dizziness is a common symptom that affects 15-35% of the population, with vertigo being one of the four main categories.

    • Vertigo can be caused by diseases of the central or peripheral nervous system, with central origin vertigo potentially being life-threatening.

    • The HINTS examination is essential to distinguish between central and peripheral causes of vertigo.

    • A detailed history and clinical examination can help to make a definite and accurate diagnosis and treatment plan.

    • Many patients are admitted to dizziness clinics with long-standing dizziness due to a lack of expertise in dizziness and inappropriate treatment.

    • A holistic treatment combining medications, vestibular rehabilitation, physiotherapy, and psychotherapy should be initiated to improve the quality of life of these patients.

    • Dizziness can be caused by drugs used daily, specifically in older people, such as antiarrhythmics, antiepileptics, and muscle relaxants.

    • The first pivotal step in the evaluation of patients with dizziness is to distinguish the three major symptoms associated with dizziness: vertigo, near syncope, and dysequilibrium.

    • The second pivotal step is to look for clues on history and neurological examination associated with CNS disease.

    • Benign paroxysmal positional vertigo (BPPV) is the most common cause of positional vertigo.

    • The Epley maneuver is the most effective treatment for posterior canal BPPV (PC-BPPV) and is used daily in clinical practice.

    • During the acute phase of BPPV, antihistamines and anticholinergic drugs may be used to relieve nausea, vomiting, and vertigo.Diagnosis and Treatment of Vestibular Disorders

    • Roll test can identify canalolithiasis of horizontal canal BPPV (HC-BPPV), which is the second most common cause of BPPV (20%).

    • Chronic dizziness is a common condition that is often misdiagnosed by doctors who are not familiar with vestibular disorders.

    • Chronic positional vertigo was included in the ICD-11 by the World Health Organization in 2017.

    • Patients with chronic dizziness may suffer from visual vertigo due to the sensitization of optokinetic stimulus.

    • Vestibular rehabilitation is a very effective treatment for chronic dizziness due to unilateral or bilateral vestibulopathy.

    • Cinnarizine is an antihistamine with mild antivertiginous action and strong antiemetic action.

    • Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are very effective for persistent postural-perceptual dizziness (phobic vertigo).

    • Vestibular neuritis is usually caused by inflammation of the vestibular part of the eighth cranial nerve and it is ascribed to acute unilateral loss of vestibular function.

    • Vestibular neuritis affects people between the ages of 30 and 60, with the majority of cases occurring in people between the ages of 40 and 50.

    • The most common symptoms of vestibular neuritis are vertigo, nausea, vomiting, balance problems, and gait inconsistency.

    • A basic neuro-otological examination, which includes a normal horizontal head impulse test, direction-changing nystagmus, and skew deviation (HINTS), can consistently detect central vertigo with high sensitivity and specificity.

    • Symptomatic treatment with antivertiginous drugs (e.g. dimenhydrinate and scopolamine) can be used to reduce vertigo, dizziness, and nausea/vomiting in vestibular neuritis.

    • Physical therapy (vestibular exercises and balance training) to improve central vestibular compensation are also part of the treatment for vestibular neuritis.Overview of Central Vestibular Disorders, Vestibular Migraine, and Meniere's Disease

    • Common causes of central vestibular disorders include damage to the vestibular nuclei in the brainstem or injury to the vestibulocerebellum.

    • Symptoms of central vertigo may include severe imbalance, neurologic deficits, less prominent movement illusion, nausea, and central nystagmus.

    • Peripheral vertigo is usually accompanied by more severe nausea and vomiting than central vertigo.

    • Patients with peripheral vestibular lesions can walk despite experiencing imbalance, while those with central vestibular deficits may be unable to stand or walk.

    • Auditory symptoms such as hearing loss and tinnitus are prevalent in peripheral lesions involving the labyrinth or VIII nerve.

    • Diplopia and dysconjugate gaze are neurological indications of a central lesion, while they may only be present for a few days in the case of an acute peripheral vestibular lesion.

    • Head-shaking nystagmus is a valuable finding for identifying patients with unilateral vestibular hypofunction.

    • Vestibular migraine is more prevalent than other vestibular disorders, and the majority of patients suffer from episodic migraine.

    • Symptoms of vestibular migraine include internal vertigo, triggered vertigo, unsteadiness, headaches, tinnitus, and visual distortions.

    • The pathogenesis of vestibular migraine is still unclear, but genetic, inflammatory, and neurochemical mechanisms have been proposed.

    • Prophylactic medications are the mainstay for the management of vestibular migraine, and non-pharmaceutical methods such as vestibular rehabilitation may also be helpful.

    • Meniere's disease affects the peripheral audiovestibular system and is characterized by vertigo, tinnitus, aural fullness, and hearing loss. The exact etiology of Meniere's disease is unclear, but environmental and genetic factors seem to play a role.Diagnosis and Management of Ménière's Disease and Cervical Vertigo

    • Ménière's Disease (MD) is a disorder of the inner ear characterized by vertigo, tinnitus, aural fullness, and hearing loss.

    • The current diagnostic criteria for MD include two or more spontaneous attacks of vertigo, low to medium frequency sensorineural hearing loss, and fluctuating aural symptoms.

    • Diagnostic tests for MD include audiological evaluation, VNG, and VEMPs. MRI may be necessary to exclude retrocochlear pathology.

    • Preventive first-line management for MD includes lifestyle modifications such as sleeping well, reducing stress, avoiding alcohol, tobacco, and caffeine, and adopting a low-salt diet. Betahistine and diuretics are commonly used medications.

    • Second-line management for MD includes intratympanic steroid injection, while third-line management includes endolymphatic sac surgery.

    • Fourth-line management for MD is intratympanic injection of gentamicin, while fifth-line management includes labyrinthectomy and vestibular neurectomy.

    • Cervical vertigo is a type of vertigo that originates from the cervical spine and is characterized by neck pain and stiffness.

    • Four hypotheses explain vertigo of cervical origin, including proprioceptive cervical vertigo, rotational vertebral artery vertigo, Barré-Lieou syndrome, and migraine-associated cervicogenic vertigo.

    • The diagnosis of cervical vertigo is difficult, and the symptom of neck pain is crucial in the diagnosis.

    • Treatment for cervical vertigo includes manual therapy, vestibular rehabilitation, and physical therapy.

    • Several studies have shown that manual therapy, specifically sustained natural apophyseal glides, is useful in the treatment of vertigo caused by cervical dysfunction.

    • A combination of manual therapy and vestibular rehabilitation has also shown positive results in published case studies.

    A Holistic Approach to Vertigo: A Practical Update

    • Dizziness is a common symptom that affects 15-35% of the population, with vertigo being one of the four main categories.

    • Vertigo can be caused by diseases of the central or peripheral nervous system, with central origin vertigo potentially being life-threatening.

    • The HINTS examination is essential to distinguish between central and peripheral causes of vertigo.

    • A detailed history and clinical examination can help to make a definite and accurate diagnosis and treatment plan.

    • Many patients are admitted to dizziness clinics with long-standing dizziness due to a lack of expertise in dizziness and inappropriate treatment.

    • A holistic treatment combining medications, vestibular rehabilitation, physiotherapy, and psychotherapy should be initiated to improve the quality of life of these patients.

    • Dizziness can be caused by drugs used daily, specifically in older people, such as antiarrhythmics, antiepileptics, and muscle relaxants.

    • The first pivotal step in the evaluation of patients with dizziness is to distinguish the three major symptoms associated with dizziness: vertigo, near syncope, and dysequilibrium.

    • The second pivotal step is to look for clues on history and neurological examination associated with CNS disease.

    • Benign paroxysmal positional vertigo (BPPV) is the most common cause of positional vertigo.

    • The Epley maneuver is the most effective treatment for posterior canal BPPV (PC-BPPV) and is used daily in clinical practice.

    • During the acute phase of BPPV, antihistamines and anticholinergic drugs may be used to relieve nausea, vomiting, and vertigo.Diagnosis and Treatment of Vestibular Disorders

    • Roll test can identify canalolithiasis of horizontal canal BPPV (HC-BPPV), which is the second most common cause of BPPV (20%).

    • Chronic dizziness is a common condition that is often misdiagnosed by doctors who are not familiar with vestibular disorders.

    • Chronic positional vertigo was included in the ICD-11 by the World Health Organization in 2017.

    • Patients with chronic dizziness may suffer from visual vertigo due to the sensitization of optokinetic stimulus.

    • Vestibular rehabilitation is a very effective treatment for chronic dizziness due to unilateral or bilateral vestibulopathy.

    • Cinnarizine is an antihistamine with mild antivertiginous action and strong antiemetic action.

    • Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are very effective for persistent postural-perceptual dizziness (phobic vertigo).

    • Vestibular neuritis is usually caused by inflammation of the vestibular part of the eighth cranial nerve and it is ascribed to acute unilateral loss of vestibular function.

    • Vestibular neuritis affects people between the ages of 30 and 60, with the majority of cases occurring in people between the ages of 40 and 50.

    • The most common symptoms of vestibular neuritis are vertigo, nausea, vomiting, balance problems, and gait inconsistency.

    • A basic neuro-otological examination, which includes a normal horizontal head impulse test, direction-changing nystagmus, and skew deviation (HINTS), can consistently detect central vertigo with high sensitivity and specificity.

    • Symptomatic treatment with antivertiginous drugs (e.g. dimenhydrinate and scopolamine) can be used to reduce vertigo, dizziness, and nausea/vomiting in vestibular neuritis.

    • Physical therapy (vestibular exercises and balance training) to improve central vestibular compensation are also part of the treatment for vestibular neuritis.Overview of Central Vestibular Disorders, Vestibular Migraine, and Meniere's Disease

    • Common causes of central vestibular disorders include damage to the vestibular nuclei in the brainstem or injury to the vestibulocerebellum.

    • Symptoms of central vertigo may include severe imbalance, neurologic deficits, less prominent movement illusion, nausea, and central nystagmus.

    • Peripheral vertigo is usually accompanied by more severe nausea and vomiting than central vertigo.

    • Patients with peripheral vestibular lesions can walk despite experiencing imbalance, while those with central vestibular deficits may be unable to stand or walk.

    • Auditory symptoms such as hearing loss and tinnitus are prevalent in peripheral lesions involving the labyrinth or VIII nerve.

    • Diplopia and dysconjugate gaze are neurological indications of a central lesion, while they may only be present for a few days in the case of an acute peripheral vestibular lesion.

    • Head-shaking nystagmus is a valuable finding for identifying patients with unilateral vestibular hypofunction.

    • Vestibular migraine is more prevalent than other vestibular disorders, and the majority of patients suffer from episodic migraine.

    • Symptoms of vestibular migraine include internal vertigo, triggered vertigo, unsteadiness, headaches, tinnitus, and visual distortions.

    • The pathogenesis of vestibular migraine is still unclear, but genetic, inflammatory, and neurochemical mechanisms have been proposed.

    • Prophylactic medications are the mainstay for the management of vestibular migraine, and non-pharmaceutical methods such as vestibular rehabilitation may also be helpful.

    • Meniere's disease affects the peripheral audiovestibular system and is characterized by vertigo, tinnitus, aural fullness, and hearing loss. The exact etiology of Meniere's disease is unclear, but environmental and genetic factors seem to play a role.Diagnosis and Management of Ménière's Disease and Cervical Vertigo

    • Ménière's Disease (MD) is a disorder of the inner ear characterized by vertigo, tinnitus, aural fullness, and hearing loss.

    • The current diagnostic criteria for MD include two or more spontaneous attacks of vertigo, low to medium frequency sensorineural hearing loss, and fluctuating aural symptoms.

    • Diagnostic tests for MD include audiological evaluation, VNG, and VEMPs. MRI may be necessary to exclude retrocochlear pathology.

    • Preventive first-line management for MD includes lifestyle modifications such as sleeping well, reducing stress, avoiding alcohol, tobacco, and caffeine, and adopting a low-salt diet. Betahistine and diuretics are commonly used medications.

    • Second-line management for MD includes intratympanic steroid injection, while third-line management includes endolymphatic sac surgery.

    • Fourth-line management for MD is intratympanic injection of gentamicin, while fifth-line management includes labyrinthectomy and vestibular neurectomy.

    • Cervical vertigo is a type of vertigo that originates from the cervical spine and is characterized by neck pain and stiffness.

    • Four hypotheses explain vertigo of cervical origin, including proprioceptive cervical vertigo, rotational vertebral artery vertigo, Barré-Lieou syndrome, and migraine-associated cervicogenic vertigo.

    • The diagnosis of cervical vertigo is difficult, and the symptom of neck pain is crucial in the diagnosis.

    • Treatment for cervical vertigo includes manual therapy, vestibular rehabilitation, and physical therapy.

    • Several studies have shown that manual therapy, specifically sustained natural apophyseal glides, is useful in the treatment of vertigo caused by cervical dysfunction.

    • A combination of manual therapy and vestibular rehabilitation has also shown positive results in published case studies.

    A Holistic Approach to Vertigo: A Practical Update

    • Dizziness is a common symptom that affects 15-35% of the population, with vertigo being one of the four main categories.

    • Vertigo can be caused by diseases of the central or peripheral nervous system, with central origin vertigo potentially being life-threatening.

    • The HINTS examination is essential to distinguish between central and peripheral causes of vertigo.

    • A detailed history and clinical examination can help to make a definite and accurate diagnosis and treatment plan.

    • Many patients are admitted to dizziness clinics with long-standing dizziness due to a lack of expertise in dizziness and inappropriate treatment.

    • A holistic treatment combining medications, vestibular rehabilitation, physiotherapy, and psychotherapy should be initiated to improve the quality of life of these patients.

    • Dizziness can be caused by drugs used daily, specifically in older people, such as antiarrhythmics, antiepileptics, and muscle relaxants.

    • The first pivotal step in the evaluation of patients with dizziness is to distinguish the three major symptoms associated with dizziness: vertigo, near syncope, and dysequilibrium.

    • The second pivotal step is to look for clues on history and neurological examination associated with CNS disease.

    • Benign paroxysmal positional vertigo (BPPV) is the most common cause of positional vertigo.

    • The Epley maneuver is the most effective treatment for posterior canal BPPV (PC-BPPV) and is used daily in clinical practice.

    • During the acute phase of BPPV, antihistamines and anticholinergic drugs may be used to relieve nausea, vomiting, and vertigo.Diagnosis and Treatment of Vestibular Disorders

    • Roll test can identify canalolithiasis of horizontal canal BPPV (HC-BPPV), which is the second most common cause of BPPV (20%).

    • Chronic dizziness is a common condition that is often misdiagnosed by doctors who are not familiar with vestibular disorders.

    • Chronic positional vertigo was included in the ICD-11 by the World Health Organization in 2017.

    • Patients with chronic dizziness may suffer from visual vertigo due to the sensitization of optokinetic stimulus.

    • Vestibular rehabilitation is a very effective treatment for chronic dizziness due to unilateral or bilateral vestibulopathy.

    • Cinnarizine is an antihistamine with mild antivertiginous action and strong antiemetic action.

    • Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are very effective for persistent postural-perceptual dizziness (phobic vertigo).

    • Vestibular neuritis is usually caused by inflammation of the vestibular part of the eighth cranial nerve and it is ascribed to acute unilateral loss of vestibular function.

    • Vestibular neuritis affects people between the ages of 30 and 60, with the majority of cases occurring in people between the ages of 40 and 50.

    • The most common symptoms of vestibular neuritis are vertigo, nausea, vomiting, balance problems, and gait inconsistency.

    • A basic neuro-otological examination, which includes a normal horizontal head impulse test, direction-changing nystagmus, and skew deviation (HINTS), can consistently detect central vertigo with high sensitivity and specificity.

    • Symptomatic treatment with antivertiginous drugs (e.g. dimenhydrinate and scopolamine) can be used to reduce vertigo, dizziness, and nausea/vomiting in vestibular neuritis.

    • Physical therapy (vestibular exercises and balance training) to improve central vestibular compensation are also part of the treatment for vestibular neuritis.Overview of Central Vestibular Disorders, Vestibular Migraine, and Meniere's Disease

    • Common causes of central vestibular disorders include damage to the vestibular nuclei in the brainstem or injury to the vestibulocerebellum.

    • Symptoms of central vertigo may include severe imbalance, neurologic deficits, less prominent movement illusion, nausea, and central nystagmus.

    • Peripheral vertigo is usually accompanied by more severe nausea and vomiting than central vertigo.

    • Patients with peripheral vestibular lesions can walk despite experiencing imbalance, while those with central vestibular deficits may be unable to stand or walk.

    • Auditory symptoms such as hearing loss and tinnitus are prevalent in peripheral lesions involving the labyrinth or VIII nerve.

    • Diplopia and dysconjugate gaze are neurological indications of a central lesion, while they may only be present for a few days in the case of an acute peripheral vestibular lesion.

    • Head-shaking nystagmus is a valuable finding for identifying patients with unilateral vestibular hypofunction.

    • Vestibular migraine is more prevalent than other vestibular disorders, and the majority of patients suffer from episodic migraine.

    • Symptoms of vestibular migraine include internal vertigo, triggered vertigo, unsteadiness, headaches, tinnitus, and visual distortions.

    • The pathogenesis of vestibular migraine is still unclear, but genetic, inflammatory, and neurochemical mechanisms have been proposed.

    • Prophylactic medications are the mainstay for the management of vestibular migraine, and non-pharmaceutical methods such as vestibular rehabilitation may also be helpful.

    • Meniere's disease affects the peripheral audiovestibular system and is characterized by vertigo, tinnitus, aural fullness, and hearing loss. The exact etiology of Meniere's disease is unclear, but environmental and genetic factors seem to play a role.Diagnosis and Management of Ménière's Disease and Cervical Vertigo

    • Ménière's Disease (MD) is a disorder of the inner ear characterized by vertigo, tinnitus, aural fullness, and hearing loss.

    • The current diagnostic criteria for MD include two or more spontaneous attacks of vertigo, low to medium frequency sensorineural hearing loss, and fluctuating aural symptoms.

    • Diagnostic tests for MD include audiological evaluation, VNG, and VEMPs. MRI may be necessary to exclude retrocochlear pathology.

    • Preventive first-line management for MD includes lifestyle modifications such as sleeping well, reducing stress, avoiding alcohol, tobacco, and caffeine, and adopting a low-salt diet. Betahistine and diuretics are commonly used medications.

    • Second-line management for MD includes intratympanic steroid injection, while third-line management includes endolymphatic sac surgery.

    • Fourth-line management for MD is intratympanic injection of gentamicin, while fifth-line management includes labyrinthectomy and vestibular neurectomy.

    • Cervical vertigo is a type of vertigo that originates from the cervical spine and is characterized by neck pain and stiffness.

    • Four hypotheses explain vertigo of cervical origin, including proprioceptive cervical vertigo, rotational vertebral artery vertigo, Barré-Lieou syndrome, and migraine-associated cervicogenic vertigo.

    • The diagnosis of cervical vertigo is difficult, and the symptom of neck pain is crucial in the diagnosis.

    • Treatment for cervical vertigo includes manual therapy, vestibular rehabilitation, and physical therapy.

    • Several studies have shown that manual therapy, specifically sustained natural apophyseal glides, is useful in the treatment of vertigo caused by cervical dysfunction.

    • A combination of manual therapy and vestibular rehabilitation has also shown positive results in published case studies.

    A Holistic Approach to Vertigo: A Practical Update

    • Dizziness is a common symptom that affects 15-35% of the population, with vertigo being one of the four main categories.

    • Vertigo can be caused by diseases of the central or peripheral nervous system, with central origin vertigo potentially being life-threatening.

    • The HINTS examination is essential to distinguish between central and peripheral causes of vertigo.

    • A detailed history and clinical examination can help to make a definite and accurate diagnosis and treatment plan.

    • Many patients are admitted to dizziness clinics with long-standing dizziness due to a lack of expertise in dizziness and inappropriate treatment.

    • A holistic treatment combining medications, vestibular rehabilitation, physiotherapy, and psychotherapy should be initiated to improve the quality of life of these patients.

    • Dizziness can be caused by drugs used daily, specifically in older people, such as antiarrhythmics, antiepileptics, and muscle relaxants.

    • The first pivotal step in the evaluation of patients with dizziness is to distinguish the three major symptoms associated with dizziness: vertigo, near syncope, and dysequilibrium.

    • The second pivotal step is to look for clues on history and neurological examination associated with CNS disease.

    • Benign paroxysmal positional vertigo (BPPV) is the most common cause of positional vertigo.

    • The Epley maneuver is the most effective treatment for posterior canal BPPV (PC-BPPV) and is used daily in clinical practice.

    • During the acute phase of BPPV, antihistamines and anticholinergic drugs may be used to relieve nausea, vomiting, and vertigo.Diagnosis and Treatment of Vestibular Disorders

    • Roll test can identify canalolithiasis of horizontal canal BPPV (HC-BPPV), which is the second most common cause of BPPV (20%).

    • Chronic dizziness is a common condition that is often misdiagnosed by doctors who are not familiar with vestibular disorders.

    • Chronic positional vertigo was included in the ICD-11 by the World Health Organization in 2017.

    • Patients with chronic dizziness may suffer from visual vertigo due to the sensitization of optokinetic stimulus.

    • Vestibular rehabilitation is a very effective treatment for chronic dizziness due to unilateral or bilateral vestibulopathy.

    • Cinnarizine is an antihistamine with mild antivertiginous action and strong antiemetic action.

    • Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are very effective for persistent postural-perceptual dizziness (phobic vertigo).

    • Vestibular neuritis is usually caused by inflammation of the vestibular part of the eighth cranial nerve and it is ascribed to acute unilateral loss of vestibular function.

    • Vestibular neuritis affects people between the ages of 30 and 60, with the majority of cases occurring in people between the ages of 40 and 50.

    • The most common symptoms of vestibular neuritis are vertigo, nausea, vomiting, balance problems, and gait inconsistency.

    • A basic neuro-otological examination, which includes a normal horizontal head impulse test, direction-changing nystagmus, and skew deviation (HINTS), can consistently detect central vertigo with high sensitivity and specificity.

    • Symptomatic treatment with antivertiginous drugs (e.g. dimenhydrinate and scopolamine) can be used to reduce vertigo, dizziness, and nausea/vomiting in vestibular neuritis.

    • Physical therapy (vestibular exercises and balance training) to improve central vestibular compensation are also part of the treatment for vestibular neuritis.Overview of Central Vestibular Disorders, Vestibular Migraine, and Meniere's Disease

    • Common causes of central vestibular disorders include damage to the vestibular nuclei in the brainstem or injury to the vestibulocerebellum.

    • Symptoms of central vertigo may include severe imbalance, neurologic deficits, less prominent movement illusion, nausea, and central nystagmus.

    • Peripheral vertigo is usually accompanied by more severe nausea and vomiting than central vertigo.

    • Patients with peripheral vestibular lesions can walk despite experiencing imbalance, while those with central vestibular deficits may be unable to stand or walk.

    • Auditory symptoms such as hearing loss and tinnitus are prevalent in peripheral lesions involving the labyrinth or VIII nerve.

    • Diplopia and dysconjugate gaze are neurological indications of a central lesion, while they may only be present for a few days in the case of an acute peripheral vestibular lesion.

    • Head-shaking nystagmus is a valuable finding for identifying patients with unilateral vestibular hypofunction.

    • Vestibular migraine is more prevalent than other vestibular disorders, and the majority of patients suffer from episodic migraine.

    • Symptoms of vestibular migraine include internal vertigo, triggered vertigo, unsteadiness, headaches, tinnitus, and visual distortions.

    • The pathogenesis of vestibular migraine is still unclear, but genetic, inflammatory, and neurochemical mechanisms have been proposed.

    • Prophylactic medications are the mainstay for the management of vestibular migraine, and non-pharmaceutical methods such as vestibular rehabilitation may also be helpful.

    • Meniere's disease affects the peripheral audiovestibular system and is characterized by vertigo, tinnitus, aural fullness, and hearing loss. The exact etiology of Meniere's disease is unclear, but environmental and genetic factors seem to play a role.Diagnosis and Management of Ménière's Disease and Cervical Vertigo

    • Ménière's Disease (MD) is a disorder of the inner ear characterized by vertigo, tinnitus, aural fullness, and hearing loss.

    • The current diagnostic criteria for MD include two or more spontaneous attacks of vertigo, low to medium frequency sensorineural hearing loss, and fluctuating aural symptoms.

    • Diagnostic tests for MD include audiological evaluation, VNG, and VEMPs. MRI may be necessary to exclude retrocochlear pathology.

    • Preventive first-line management for MD includes lifestyle modifications such as sleeping well, reducing stress, avoiding alcohol, tobacco, and caffeine, and adopting a low-salt diet. Betahistine and diuretics are commonly used medications.

    • Second-line management for MD includes intratympanic steroid injection, while third-line management includes endolymphatic sac surgery.

    • Fourth-line management for MD is intratympanic injection of gentamicin, while fifth-line management includes labyrinthectomy and vestibular neurectomy.

    • Cervical vertigo is a type of vertigo that originates from the cervical spine and is characterized by neck pain and stiffness.

    • Four hypotheses explain vertigo of cervical origin, including proprioceptive cervical vertigo, rotational vertebral artery vertigo, Barré-Lieou syndrome, and migraine-associated cervicogenic vertigo.

    • The diagnosis of cervical vertigo is difficult, and the symptom of neck pain is crucial in the diagnosis.

    • Treatment for cervical vertigo includes manual therapy, vestibular rehabilitation, and physical therapy.

    • Several studies have shown that manual therapy, specifically sustained natural apophyseal glides, is useful in the treatment of vertigo caused by cervical dysfunction.

    • A combination of manual therapy and vestibular rehabilitation has also shown positive results in published case studies.

    A Holistic Approach to Vertigo: A Practical Update

    • Dizziness is a common symptom that affects 15-35% of the population, with vertigo being one of the four main categories.

    • Vertigo can be caused by diseases of the central or peripheral nervous system, with central origin vertigo potentially being life-threatening.

    • The HINTS examination is essential to distinguish between central and peripheral causes of vertigo.

    • A detailed history and clinical examination can help to make a definite and accurate diagnosis and treatment plan.

    • Many patients are admitted to dizziness clinics with long-standing dizziness due to a lack of expertise in dizziness and inappropriate treatment.

    • A holistic treatment combining medications, vestibular rehabilitation, physiotherapy, and psychotherapy should be initiated to improve the quality of life of these patients.

    • Dizziness can be caused by drugs used daily, specifically in older people, such as antiarrhythmics, antiepileptics, and muscle relaxants.

    • The first pivotal step in the evaluation of patients with dizziness is to distinguish the three major symptoms associated with dizziness: vertigo, near syncope, and dysequilibrium.

    • The second pivotal step is to look for clues on history and neurological examination associated with CNS disease.

    • Benign paroxysmal positional vertigo (BPPV) is the most common cause of positional vertigo.

    • The Epley maneuver is the most effective treatment for posterior canal BPPV (PC-BPPV) and is used daily in clinical practice.

    • During the acute phase of BPPV, antihistamines and anticholinergic drugs may be used to relieve nausea, vomiting, and vertigo.Diagnosis and Treatment of Vestibular Disorders

    • Roll test can identify canalolithiasis of horizontal canal BPPV (HC-BPPV), which is the second most common cause of BPPV (20%).

    • Chronic dizziness is a common condition that is often misdiagnosed by doctors who are not familiar with vestibular disorders.

    • Chronic positional vertigo was included in the ICD-11 by the World Health Organization in 2017.

    • Patients with chronic dizziness may suffer from visual vertigo due to the sensitization of optokinetic stimulus.

    • Vestibular rehabilitation is a very effective treatment for chronic dizziness due to unilateral or bilateral vestibulopathy.

    • Cinnarizine is an antihistamine with mild antivertiginous action and strong antiemetic action.

    • Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are very effective for persistent postural-perceptual dizziness (phobic vertigo).

    • Vestibular neuritis is usually caused by inflammation of the vestibular part of the eighth cranial nerve and it is ascribed to acute unilateral loss of vestibular function.

    • Vestibular neuritis affects people between the ages of 30 and 60, with the majority of cases occurring in people between the ages of 40 and 50.

    • The most common symptoms of vestibular neuritis are vertigo, nausea, vomiting, balance problems, and gait inconsistency.

    • A basic neuro-otological examination, which includes a normal horizontal head impulse test, direction-changing nystagmus, and skew deviation (HINTS), can consistently detect central vertigo with high sensitivity and specificity.

    • Symptomatic treatment with antivertiginous drugs (e.g. dimenhydrinate and scopolamine) can be used to reduce vertigo, dizziness, and nausea/vomiting in vestibular neuritis.

    • Physical therapy (vestibular exercises and balance training) to improve central vestibular compensation are also part of the treatment for vestibular neuritis.Overview of Central Vestibular Disorders, Vestibular Migraine, and Meniere's Disease

    • Common causes of central vestibular disorders include damage to the vestibular nuclei in the brainstem or injury to the vestibulocerebellum.

    • Symptoms of central vertigo may include severe imbalance, neurologic deficits, less prominent movement illusion, nausea, and central nystagmus.

    • Peripheral vertigo is usually accompanied by more severe nausea and vomiting than central vertigo.

    • Patients with peripheral vestibular lesions can walk despite experiencing imbalance, while those with central vestibular deficits may be unable to stand or walk.

    • Auditory symptoms such as hearing loss and tinnitus are prevalent in peripheral lesions involving the labyrinth or VIII nerve.

    • Diplopia and dysconjugate gaze are neurological indications of a central lesion, while they may only be present for a few days in the case of an acute peripheral vestibular lesion.

    • Head-shaking nystagmus is a valuable finding for identifying patients with unilateral vestibular hypofunction.

    • Vestibular migraine is more prevalent than other vestibular disorders, and the majority of patients suffer from episodic migraine.

    • Symptoms of vestibular migraine include internal vertigo, triggered vertigo, unsteadiness, headaches, tinnitus, and visual distortions.

    • The pathogenesis of vestibular migraine is still unclear, but genetic, inflammatory, and neurochemical mechanisms have been proposed.

    • Prophylactic medications are the mainstay for the management of vestibular migraine, and non-pharmaceutical methods such as vestibular rehabilitation may also be helpful.

    • Meniere's disease affects the peripheral audiovestibular system and is characterized by vertigo, tinnitus, aural fullness, and hearing loss. The exact etiology of Meniere's disease is unclear, but environmental and genetic factors seem to play a role.Diagnosis and Management of Ménière's Disease and Cervical Vertigo

    • Ménière's Disease (MD) is a disorder of the inner ear characterized by vertigo, tinnitus, aural fullness, and hearing loss.

    • The current diagnostic criteria for MD include two or more spontaneous attacks of vertigo, low to medium frequency sensorineural hearing loss, and fluctuating aural symptoms.

    • Diagnostic tests for MD include audiological evaluation, VNG, and VEMPs. MRI may be necessary to exclude retrocochlear pathology.

    • Preventive first-line management for MD includes lifestyle modifications such as sleeping well, reducing stress, avoiding alcohol, tobacco, and caffeine, and adopting a low-salt diet. Betahistine and diuretics are commonly used medications.

    • Second-line management for MD includes intratympanic steroid injection, while third-line management includes endolymphatic sac surgery.

    • Fourth-line management for MD is intratympanic injection of gentamicin, while fifth-line management includes labyrinthectomy and vestibular neurectomy.

    • Cervical vertigo is a type of vertigo that originates from the cervical spine and is characterized by neck pain and stiffness.

    • Four hypotheses explain vertigo of cervical origin, including proprioceptive cervical vertigo, rotational vertebral artery vertigo, Barré-Lieou syndrome, and migraine-associated cervicogenic vertigo.

    • The diagnosis of cervical vertigo is difficult, and the symptom of neck pain is crucial in the diagnosis.

    • Treatment for cervical vertigo includes manual therapy, vestibular rehabilitation, and physical therapy.

    • Several studies have shown that manual therapy, specifically sustained natural apophyseal glides, is useful in the treatment of vertigo caused by cervical dysfunction.

    • A combination of manual therapy and vestibular rehabilitation has also shown positive results in published case studies.

    Intensive Care in Traumatic Brain Injury: Multimodal Monitoring and Neuroprotection

    • Traumatic brain injury (TBI) is a major cause of death and disability worldwide.

    • TBI affects people of all ages, but older people are more at risk due to falls.

    • TBI produces various lesions ranging from mild to severe injury.

    • Primary injuries are caused by external physical forces, while secondary injuries worsen over time due to molecular and cellular pathways.

    • Secondary injuries may be promoted by secondary insults such as hypotension, hypoxia, and hyperglycemia.

    • TBI is not a single entity, and therapeutic needs vary from patient to patient.

    • Multimodal monitoring and imaging are necessary to tailor treatment approaches.

    • A specialized neurointensive approach is required for patients with severe TBI.

    • The approach aims to prevent secondary insults, maintain cerebral homoeostasis, and preserve rehabilitation potential.

    • Clinical examination remains a fundamental monitoring procedure, even in patients who undergo imaging.

    • The approach involves a multidisciplinary team consisting of different medical specialists, ICU nurses, physiotherapists, and ergo-/logotherapists.

    • Treatment guidelines frequently applied to all patients are usually derived from cohort studies, which ignore differences in underlying pathological features and pre-injury conditions.Neurological Monitoring and Management in Traumatic Brain Injury

    • Neurological evaluation in TBI patients is important to identify neurological deterioration and potential indications for surgical interventions.

    • Glasgow Coma Score (GCS) assessment is frequently performed at the accident site and may overestimate the degree of disturbance of consciousness.

    • Motor response is the most robust and important part of GCS evaluation in patients who are deeply sedated.

    • Automated pupillometry is a portable technique that measures pupil size and light reactivity, automatically improving inter-rater accuracy.

    • More than 40% of TBI patients show substantial worsening during the first 48 hours in the ICU, which is significantly associated with high ICP and poor outcome.

    • A routine second CT scan within 24 hours should be performed in all comatose patients and if any substantial clinical worsening occurs or ICP rises.

    • ICP monitoring is indicated in patients with severe TBI (GCS ≤8) and can reduce early mortality.

    • Protocols for ICP therapy vary in detail and are mainly based on experience and consensus guidelines but not on clear scientific evidence.

    • Three main strategies proposed for ICP therapy are traditional approach, Rosner concept, and Lund concept.

    • CPP as a surrogate for relative cerebral perfusion is more important than just targeting an increased ICP.

    • The critical threshold for CPP lies between 50 and 60 mmHg, and brain monitoring techniques could provide complementary and specific information that allows for selecting the optimal CPP for the individual patient.

    • The CPP-targeted treatment concept includes prevention of ICP rises and maintenance of CPP by basic measures, and active interventions might be warranted if ICP increases.Advanced Management Strategies for Elevated Intracranial Pressure in Traumatic Brain Injury

    • Hyperosmolar agents such as hypertonic saline, Na-lactate, and mannitol are effective in reducing intracranial pressure (ICP) but their contribution to neurological outcomes is unclear.

    • Mannitol is less effective than hypertonic saline and Na-lactate in reducing brain swelling and does not improve tissue oxygenation.

    • Hypertonic saline reduces the accumulation of excitatory amino acids, preventing glutamine toxicity and neuronal damage.

    • Metabolic suppression with barbiturate coma and hypothermia are aggressive treatments for refractory elevated ICP but have no solid evidence of improved outcomes and carry risks of cardiovascular depression and infections.

    • Decompressive craniectomy is a last-resort treatment for severe refractory ICP, reducing ICP and mortality while increasing the incidence of unfavorable outcomes at six months.

    • The Lund concept is a therapeutic approach that focuses on the reduction of ICP by decreasing intracranial volumes, emphasizing a reduction in microvascular pressures to minimize cerebral edema formation.

    • The Lund concept includes reduction of stress and brain metabolism, reduction of hydrostatic capillary pressure, and maintenance of colloid-oncotic pressure, among others, with targets of ICP <20-22 mmHg and CPP 50-70 mmHg.

    • While the Lund concept has limited evidence of superiority compared to a CPP-targeted protocol, there has been convergence between the two concepts with a target CPP of 60-70 mmHg in the Lund concept and not above 70 mmHg in the CPP-targeted protocol.

    • Advanced bedside physiological monitoring techniques such as jugular bulb oximetry, arteriovenous difference in lactate, brain tissue partial tension of oxygen, autoregulation assessment, continuous EEG, and imaging modalities can provide more precise understanding of the influencing factors, allowing for better-tailored therapies.

    • Jugular bulb oximetry provides continuous monitoring of SjVO2, allowing estimation of the balance between global cerebral oxygen delivery and utilization and reflects cerebral oxygen deficit.

    • Brain tissue partial tension of oxygen provides a continuous measurement of extracellular oxygen tension as an indicator of the adequacy of oxygen delivery and consumption, and the cerebral metabolic rate of oxygen.

    • A proposed algorithm to manage abnormal SjVO2 includes optimizing CPP, considering hyperosmolar therapy, and considering hyperventilation, among others. Brain tissue partial tension of oxygen can guide management strategies such as hyperoxia or hyperventilation.Assessment Techniques for Monitoring Brain Injury

    • PbtO2 is a measure of brain oxygenation with an ischemic threshold between 5 and 20 mmHg; values below 20 mmHg indicate inadequate oxygen supply and are associated with worse outcomes after traumatic brain injury (TBI).

    • PbtO2 is modulated by oxygen diffusion, which can be affected by tissue and endothelial edema and microvascular collapse, making it difficult to define adequate target values.

    • Approaches to increase PbtO2 levels include increasing arterial pressure and oxygen tension, and altering carbon dioxide partial pressure to enhance cerebral blood flow.

    • Manipulating PbtO2 by increasing PO2 or altering CPP (by increasing mean arterial pressure, decreasing intracranial pressure, or both) have been investigated for therapy optimization and potential prognostication.

    • CPP and ICP are not surrogates for PbtO2, and evidence supports guided therapy using brain tissue oxygenation in addition to ICP and CPP monitoring for better outcomes after TBI.

    • Microdialysis is a technique that allows for online analysis of extracellular/interstitial biochemical changes in brain glucose metabolism, cell membrane degradation, and excitatory neurotransmitter levels.

    • A high lactate:pyruvate ratio (LPR) is a marker of ischemia and/or diffusion hypoxia, leading to anaerobic glycolysis, and is an independent predictor of mortality.

    • CMD can be used to determine the optimal level of CPP in patients with TBI, and analyses can reveal alarming levels of LPR and glucose.

    • Changes in LPR may precede the onset of intracranial hypertension, and increased pericontusional LPR is significantly associated with CPP.

    • Lactate/glucose ratio may also be an indicator of increased glycolysis, while glutamate is the major excitatory amino acid in the brain and a marker for neuronal oxidative metabolism under normal conditions.

    • Cerebral microdialysis allows for detection of LPR, glutamate, and glycerol increase when electrographic seizures occur, and prolonged increases in CMD-measured glutamate levels are associated with repetitive seizures that occur over many hours.

    • Autoregulation is a physiological mechanism that maintains adequate cerebral perfusion in the presence of blood pressure changes, and the pressure–reactivity index (PRx) can be used for online real-time assessment of cerebrovascular autoregulation.

    • In severe TBI, autoregulation can be impaired or totally lost, and alternative measures based on assessment of blood flow or brain tissue oxygen reactivity may be needed. Prospective evidence from clinical studies is needed to draw definitive conclusions.

    Intensive Care in Traumatic Brain Injury: Multimodal Monitoring and Neuroprotection

    • Traumatic brain injury (TBI) is a major cause of death and disability worldwide.

    • TBI affects people of all ages, but older people are more at risk due to falls.

    • TBI produces various lesions ranging from mild to severe injury.

    • Primary injuries are caused by external physical forces, while secondary injuries worsen over time due to molecular and cellular pathways.

    • Secondary injuries may be promoted by secondary insults such as hypotension, hypoxia, and hyperglycemia.

    • TBI is not a single entity, and therapeutic needs vary from patient to patient.

    • Multimodal monitoring and imaging are necessary to tailor treatment approaches.

    • A specialized neurointensive approach is required for patients with severe TBI.

    • The approach aims to prevent secondary insults, maintain cerebral homoeostasis, and preserve rehabilitation potential.

    • Clinical examination remains a fundamental monitoring procedure, even in patients who undergo imaging.

    • The approach involves a multidisciplinary team consisting of different medical specialists, ICU nurses, physiotherapists, and ergo-/logotherapists.

    • Treatment guidelines frequently applied to all patients are usually derived from cohort studies, which ignore differences in underlying pathological features and pre-injury conditions.Neurological Monitoring and Management in Traumatic Brain Injury

    • Neurological evaluation in TBI patients is important to identify neurological deterioration and potential indications for surgical interventions.

    • Glasgow Coma Score (GCS) assessment is frequently performed at the accident site and may overestimate the degree of disturbance of consciousness.

    • Motor response is the most robust and important part of GCS evaluation in patients who are deeply sedated.

    • Automated pupillometry is a portable technique that measures pupil size and light reactivity, automatically improving inter-rater accuracy.

    • More than 40% of TBI patients show substantial worsening during the first 48 hours in the ICU, which is significantly associated with high ICP and poor outcome.

    • A routine second CT scan within 24 hours should be performed in all comatose patients and if any substantial clinical worsening occurs or ICP rises.

    • ICP monitoring is indicated in patients with severe TBI (GCS ≤8) and can reduce early mortality.

    • Protocols for ICP therapy vary in detail and are mainly based on experience and consensus guidelines but not on clear scientific evidence.

    • Three main strategies proposed for ICP therapy are traditional approach, Rosner concept, and Lund concept.

    • CPP as a surrogate for relative cerebral perfusion is more important than just targeting an increased ICP.

    • The critical threshold for CPP lies between 50 and 60 mmHg, and brain monitoring techniques could provide complementary and specific information that allows for selecting the optimal CPP for the individual patient.

    • The CPP-targeted treatment concept includes prevention of ICP rises and maintenance of CPP by basic measures, and active interventions might be warranted if ICP increases.Advanced Management Strategies for Elevated Intracranial Pressure in Traumatic Brain Injury

    • Hyperosmolar agents such as hypertonic saline, Na-lactate, and mannitol are effective in reducing intracranial pressure (ICP) but their contribution to neurological outcomes is unclear.

    • Mannitol is less effective than hypertonic saline and Na-lactate in reducing brain swelling and does not improve tissue oxygenation.

    • Hypertonic saline reduces the accumulation of excitatory amino acids, preventing glutamine toxicity and neuronal damage.

    • Metabolic suppression with barbiturate coma and hypothermia are aggressive treatments for refractory elevated ICP but have no solid evidence of improved outcomes and carry risks of cardiovascular depression and infections.

    • Decompressive craniectomy is a last-resort treatment for severe refractory ICP, reducing ICP and mortality while increasing the incidence of unfavorable outcomes at six months.

    • The Lund concept is a therapeutic approach that focuses on the reduction of ICP by decreasing intracranial volumes, emphasizing a reduction in microvascular pressures to minimize cerebral edema formation.

    • The Lund concept includes reduction of stress and brain metabolism, reduction of hydrostatic capillary pressure, and maintenance of colloid-oncotic pressure, among others, with targets of ICP <20-22 mmHg and CPP 50-70 mmHg.

    • While the Lund concept has limited evidence of superiority compared to a CPP-targeted protocol, there has been convergence between the two concepts with a target CPP of 60-70 mmHg in the Lund concept and not above 70 mmHg in the CPP-targeted protocol.

    • Advanced bedside physiological monitoring techniques such as jugular bulb oximetry, arteriovenous difference in lactate, brain tissue partial tension of oxygen, autoregulation assessment, continuous EEG, and imaging modalities can provide more precise understanding of the influencing factors, allowing for better-tailored therapies.

    • Jugular bulb oximetry provides continuous monitoring of SjVO2, allowing estimation of the balance between global cerebral oxygen delivery and utilization and reflects cerebral oxygen deficit.

    • Brain tissue partial tension of oxygen provides a continuous measurement of extracellular oxygen tension as an indicator of the adequacy of oxygen delivery and consumption, and the cerebral metabolic rate of oxygen.

    • A proposed algorithm to manage abnormal SjVO2 includes optimizing CPP, considering hyperosmolar therapy, and considering hyperventilation, among others. Brain tissue partial tension of oxygen can guide management strategies such as hyperoxia or hyperventilation.Assessment Techniques for Monitoring Brain Injury

    • PbtO2 is a measure of brain oxygenation with an ischemic threshold between 5 and 20 mmHg; values below 20 mmHg indicate inadequate oxygen supply and are associated with worse outcomes after traumatic brain injury (TBI).

    • PbtO2 is modulated by oxygen diffusion, which can be affected by tissue and endothelial edema and microvascular collapse, making it difficult to define adequate target values.

    • Approaches to increase PbtO2 levels include increasing arterial pressure and oxygen tension, and altering carbon dioxide partial pressure to enhance cerebral blood flow.

    • Manipulating PbtO2 by increasing PO2 or altering CPP (by increasing mean arterial pressure, decreasing intracranial pressure, or both) have been investigated for therapy optimization and potential prognostication.

    • CPP and ICP are not surrogates for PbtO2, and evidence supports guided therapy using brain tissue oxygenation in addition to ICP and CPP monitoring for better outcomes after TBI.

    • Microdialysis is a technique that allows for online analysis of extracellular/interstitial biochemical changes in brain glucose metabolism, cell membrane degradation, and excitatory neurotransmitter levels.

    • A high lactate:pyruvate ratio (LPR) is a marker of ischemia and/or diffusion hypoxia, leading to anaerobic glycolysis, and is an independent predictor of mortality.

    • CMD can be used to determine the optimal level of CPP in patients with TBI, and analyses can reveal alarming levels of LPR and glucose.

    • Changes in LPR may precede the onset of intracranial hypertension, and increased pericontusional LPR is significantly associated with CPP.

    • Lactate/glucose ratio may also be an indicator of increased glycolysis, while glutamate is the major excitatory amino acid in the brain and a marker for neuronal oxidative metabolism under normal conditions.

    • Cerebral microdialysis allows for detection of LPR, glutamate, and glycerol increase when electrographic seizures occur, and prolonged increases in CMD-measured glutamate levels are associated with repetitive seizures that occur over many hours.

    • Autoregulation is a physiological mechanism that maintains adequate cerebral perfusion in the presence of blood pressure changes, and the pressure–reactivity index (PRx) can be used for online real-time assessment of cerebrovascular autoregulation.

    • In severe TBI, autoregulation can be impaired or totally lost, and alternative measures based on assessment of blood flow or brain tissue oxygen reactivity may be needed. Prospective evidence from clinical studies is needed to draw definitive conclusions.

    Intensive Care in Traumatic Brain Injury: Multimodal Monitoring and Neuroprotection

    • Traumatic brain injury (TBI) is a major cause of death and disability worldwide.

    • TBI affects people of all ages, but older people are more at risk due to falls.

    • TBI produces various lesions ranging from mild to severe injury.

    • Primary injuries are caused by external physical forces, while secondary injuries worsen over time due to molecular and cellular pathways.

    • Secondary injuries may be promoted by secondary insults such as hypotension, hypoxia, and hyperglycemia.

    • TBI is not a single entity, and therapeutic needs vary from patient to patient.

    • Multimodal monitoring and imaging are necessary to tailor treatment approaches.

    • A specialized neurointensive approach is required for patients with severe TBI.

    • The approach aims to prevent secondary insults, maintain cerebral homoeostasis, and preserve rehabilitation potential.

    • Clinical examination remains a fundamental monitoring procedure, even in patients who undergo imaging.

    • The approach involves a multidisciplinary team consisting of different medical specialists, ICU nurses, physiotherapists, and ergo-/logotherapists.

    • Treatment guidelines frequently applied to all patients are usually derived from cohort studies, which ignore differences in underlying pathological features and pre-injury conditions.Neurological Monitoring and Management in Traumatic Brain Injury

    • Neurological evaluation in TBI patients is important to identify neurological deterioration and potential indications for surgical interventions.

    • Glasgow Coma Score (GCS) assessment is frequently performed at the accident site and may overestimate the degree of disturbance of consciousness.

    • Motor response is the most robust and important part of GCS evaluation in patients who are deeply sedated.

    • Automated pupillometry is a portable technique that measures pupil size and light reactivity, automatically improving inter-rater accuracy.

    • More than 40% of TBI patients show substantial worsening during the first 48 hours in the ICU, which is significantly associated with high ICP and poor outcome.

    • A routine second CT scan within 24 hours should be performed in all comatose patients and if any substantial clinical worsening occurs or ICP rises.

    • ICP monitoring is indicated in patients with severe TBI (GCS ≤8) and can reduce early mortality.

    • Protocols for ICP therapy vary in detail and are mainly based on experience and consensus guidelines but not on clear scientific evidence.

    • Three main strategies proposed for ICP therapy are traditional approach, Rosner concept, and Lund concept.

    • CPP as a surrogate for relative cerebral perfusion is more important than just targeting an increased ICP.

    • The critical threshold for CPP lies between 50 and 60 mmHg, and brain monitoring techniques could provide complementary and specific information that allows for selecting the optimal CPP for the individual patient.

    • The CPP-targeted treatment concept includes prevention of ICP rises and maintenance of CPP by basic measures, and active interventions might be warranted if ICP increases.Advanced Management Strategies for Elevated Intracranial Pressure in Traumatic Brain Injury

    • Hyperosmolar agents such as hypertonic saline, Na-lactate, and mannitol are effective in reducing intracranial pressure (ICP) but their contribution to neurological outcomes is unclear.

    • Mannitol is less effective than hypertonic saline and Na-lactate in reducing brain swelling and does not improve tissue oxygenation.

    • Hypertonic saline reduces the accumulation of excitatory amino acids, preventing glutamine toxicity and neuronal damage.

    • Metabolic suppression with barbiturate coma and hypothermia are aggressive treatments for refractory elevated ICP but have no solid evidence of improved outcomes and carry risks of cardiovascular depression and infections.

    • Decompressive craniectomy is a last-resort treatment for severe refractory ICP, reducing ICP and mortality while increasing the incidence of unfavorable outcomes at six months.

    • The Lund concept is a therapeutic approach that focuses on the reduction of ICP by decreasing intracranial volumes, emphasizing a reduction in microvascular pressures to minimize cerebral edema formation.

    • The Lund concept includes reduction of stress and brain metabolism, reduction of hydrostatic capillary pressure, and maintenance of colloid-oncotic pressure, among others, with targets of ICP <20-22 mmHg and CPP 50-70 mmHg.

    • While the Lund concept has limited evidence of superiority compared to a CPP-targeted protocol, there has been convergence between the two concepts with a target CPP of 60-70 mmHg in the Lund concept and not above 70 mmHg in the CPP-targeted protocol.

    • Advanced bedside physiological monitoring techniques such as jugular bulb oximetry, arteriovenous difference in lactate, brain tissue partial tension of oxygen, autoregulation assessment, continuous EEG, and imaging modalities can provide more precise understanding of the influencing factors, allowing for better-tailored therapies.

    • Jugular bulb oximetry provides continuous monitoring of SjVO2, allowing estimation of the balance between global cerebral oxygen delivery and utilization and reflects cerebral oxygen deficit.

    • Brain tissue partial tension of oxygen provides a continuous measurement of extracellular oxygen tension as an indicator of the adequacy of oxygen delivery and consumption, and the cerebral metabolic rate of oxygen.

    • A proposed algorithm to manage abnormal SjVO2 includes optimizing CPP, considering hyperosmolar therapy, and considering hyperventilation, among others. Brain tissue partial tension of oxygen can guide management strategies such as hyperoxia or hyperventilation.Assessment Techniques for Monitoring Brain Injury

    • PbtO2 is a measure of brain oxygenation with an ischemic threshold between 5 and 20 mmHg; values below 20 mmHg indicate inadequate oxygen supply and are associated with worse outcomes after traumatic brain injury (TBI).

    • PbtO2 is modulated by oxygen diffusion, which can be affected by tissue and endothelial edema and microvascular collapse, making it difficult to define adequate target values.

    • Approaches to increase PbtO2 levels include increasing arterial pressure and oxygen tension, and altering carbon dioxide partial pressure to enhance cerebral blood flow.

    • Manipulating PbtO2 by increasing PO2 or altering CPP (by increasing mean arterial pressure, decreasing intracranial pressure, or both) have been investigated for therapy optimization and potential prognostication.

    • CPP and ICP are not surrogates for PbtO2, and evidence supports guided therapy using brain tissue oxygenation in addition to ICP and CPP monitoring for better outcomes after TBI.

    • Microdialysis is a technique that allows for online analysis of extracellular/interstitial biochemical changes in brain glucose metabolism, cell membrane degradation, and excitatory neurotransmitter levels.

    • A high lactate:pyruvate ratio (LPR) is a marker of ischemia and/or diffusion hypoxia, leading to anaerobic glycolysis, and is an independent predictor of mortality.

    • CMD can be used to determine the optimal level of CPP in patients with TBI, and analyses can reveal alarming levels of LPR and glucose.

    • Changes in LPR may precede the onset of intracranial hypertension, and increased pericontusional LPR is significantly associated with CPP.

    • Lactate/glucose ratio may also be an indicator of increased glycolysis, while glutamate is the major excitatory amino acid in the brain and a marker for neuronal oxidative metabolism under normal conditions.

    • Cerebral microdialysis allows for detection of LPR, glutamate, and glycerol increase when electrographic seizures occur, and prolonged increases in CMD-measured glutamate levels are associated with repetitive seizures that occur over many hours.

    • Autoregulation is a physiological mechanism that maintains adequate cerebral perfusion in the presence of blood pressure changes, and the pressure–reactivity index (PRx) can be used for online real-time assessment of cerebrovascular autoregulation.

    • In severe TBI, autoregulation can be impaired or totally lost, and alternative measures based on assessment of blood flow or brain tissue oxygen reactivity may be needed. Prospective evidence from clinical studies is needed to draw definitive conclusions.

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