Vascular neuro-otology: vestibular transient ischemic attacks and chronic dizziness in the elderly

Abstract

Purpose of review To explore the differential diagnosis of posterior fossa transient ischemic attacks (TIA) associated with vertigo and/or imbalance. To review the contribution of cerebral small vessel (SVD) disease to balance dysfunction and dizziness in the elderly. Main findings TIAs involving vestibular structures that mediate the vestibulo-ocular and vestibulospinal reflexes remain a diagnostic challenge because they overlap with causes of benign episodic vertigo. Here, we summarize the results of multidisciplinary specialty efforts to improve timely recognition and intervention of peripheral and central vestibular ischemia. More papers confirm that SVD is a major cause of gait disability, falls and cognitive disorder in the elderly. Recent work shows that early stages of SVD may also be responsible for dizziness in the elderly. The predominant location of the white matter changes, in the frontal deep white matter and genu of the corpus callosum, explains the association between cognitive and balance dysfunction in SVD related symptoms. Summary The evaluation of patients with intermittent vascular vertigo represent a major diagnostic challenge, recent reviews explore the ideal design approach for a multidisciplinary study to increase early recognition and intervention. Hemispheric white matter microvascular ischemia has been the subject of research progress - advanced stages are known to cause gait disorder and dementia but early stages are associated with “idiopathic” dizziness in the elderly.

Towards an explanation for ‘unexplained’ dizziness in older people

“…Although the associations found between white matter disease markers, balance function and symptoms in the present study were not strong, well-established correlations between these variables are also weak in large cohort studies [ 39 , 40 ]. Thus, there is a general insensitivity of structural measures of small vessel disease burden to balance outcomes in the earliest stages of disease (as in our participants), although the sensitivity increases as disease progresses [ 32 , 39 , 41 ].…”

“…These factors are known to be associated with small vessel disease [ 5 , 6 , 31 ], and there is recent evidence indicating that they contribute to the emergence of ID in older people [ 5 , 6 ]. As both the dizziness and the subclinical cognitive issues are likely mediated by an underlying microangiopathy, the acronym MAID (Micro-Angiopathy-Induced-Dizziness) has been coined [ 32 ].…”