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Reference was made above to the occurrence of vertigo and nystagmus with lower and upper brainstem lesions In these cases, vestibular nuclei and their connections are implicated Auditory function is nearly always spared, since the vestibular and cochlear bers diverge upon entering the brainstem at the junction of the medulla and pons The vertigo of brainstem origin as well as the accompanying nausea, vomiting, nystagmus, and disequilibrium are generally more protracted but less severe than with labyrinthine lesions, but one can think of exceptions to this statement Nevertheless, with brainstem lesions, one often observes marked nystagmus without the slightest degree of vertigo which does not happen with labyrinthine disease The nystagmus of brainstem origin may be uni- or bidirectional, purely horizontal, vertical or rotary, and is characteristically worsened by attempted visual xation In contrast, nystagmus of labyrinthine origin is unidirectional, usually with a rotary component, and past pointing and falling are in the direction of the slow phase; a purely vertical nystagmus does not occur, and a purely horizontal nystagmus without a rotary component is unusual Furthermore, labyrinthine nystagmus is inhibited by visual xation and reverses direction with changes in the position of the head; nystagmus of brainstem origin generally displays none of these features Either may have a positional- or movement-induced worsening, but this nding is more prominent in labyrinthine disease The central localization of vertigo is con rmed by nding signs of involvement of other structures within the brainstem (cranial nerves, sensory and motor tracts, etc) The mode of onset, duration, and other features of the clinical picture depend on the nature of the causative disease, which may be vascular, demyelinative, or neoplastic Vertigo is a prominent symptom of ischemic attacks and of brainstem infarction occurring in the territory of the vertebrobasilar arteries, particularly the Wallenberg syndrome of lateral medullary infarction (page 678) On the other hand, vertigo as the sole manifestation of brainstem disease is rare Unless other symptoms and signs of brainstem disorder appear within several days, one can postulate that the vertigo has an aural origin and one can nearly always exclude vascular disease of the brainstem The same is true of multiple sclerosis, which may be the explanation of a persistent vertigo in an adolescent or young adult Vertigo of cerebellar origin is exceptional in this respect in that it may rarely be the sole manifestation of cerebellar infarction or hemorrhage, as described on pages 680 and 714 One hypothesis for cerebellar vertigo attributes it to small infarctions or compression of the lateral medulla, but this does not appear to be necessary The nystagmus and ataxia of gait (more of a propelling or pulsion to one side) that accompany acute cerebellar lesions are toward the same side (the side of the lesion), while in acute vestibulopathies, nystagmus beats away from the side of the lesion and pulsion is still toward the affected side The putative relationship of migraine to vertigo was mentioned earlier This refers to otherwise mundane migraine in which the vertigo is perhaps an aura In addition, attacks of vertigo followed by an intense unilateral and often suboccipital headache and vomiting are the characteristic features of basilar artery migraine (see page 151) The prodromal visual symptoms take the form of blindness or of photopsia that occupies all of the visual elds Between headaches, tests of cochlear and vestibular function in these patients are normal The relationship of this form of migraine to disease of the vertebral and basilar arteries is obscure.

None Ipsilateral past pointing and lateral propulsion to side of lesion Ipsilateral past pointing and lateral propulsion to side of lesion Horizontal or rotary to side opposite lesion, positional and position changing, fatigable Unidirectional positional

Labyrinths (postural vertigo, trauma, Meniere disease, ` aminoglycoside toxicity, labyrinthitis) Vestibular nerve and ganglia (vestibular neuronitis, herpes zoster)

Class 5 Delta chart (waterfall chart)

Normal or conduction or neurosensory deafness with recruitment Sometimes sensorineural deafness, without recruitment (vestibulolabyrinthitis) Sensorineural deafness without recruitment

266 Ataxia and falling ipsilaterally Ataxia present with eyes open Aphasia, visual eld, hemimotor, hemisensory, and other cerebral abnormalities, seizures No change Usually absent

Cerebellopontine angle (acoustic neuroma, glomus and other tumors)

Brainstem and cerebellum (infarcts, tumors, viral infections)

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Auditory eighth and seventh cranial nerve abnormalities; abnormal head impulse test to affected side Ipsilateral fth, seventh, ninth, tenth cranial nerves, cerebellar ataxia Increased intracranial pressure (late) Multiple cranial nerves, brainstem tract signs, cerebellar ataxia Coarse horizontal and vertical, gaze-paretic

15

Radiography and CT may be normal or abnormal Vestibular paresis on caloric testing Directional preponderance CT and MRI abnormal Vestibular paresis on caloric testing BAEPs abnormal Increased CSF protein Hyperactive labyrinths or directional preponderance on caloric testing CT, MRI, and BAEPs abnormal in most cases No change in caloric responses CT and EEG may be abnormal

Finally, mention should be made of a familial vestibulocerebellar syndrome, beginning in childhood or early adult life and characterized by recurrent episodes of vertigo and imbalance Diplopia and dysarthria complicate some attacks, which seem to be precipitated by extreme exertion and emotion Repeated attacks are followed by a mild, persistent ataxia, mainly of the trunk This disorder was rst described by Farmer and Mustian and more recently by Baloh and Winder, who have pointed out that both the episodic vertigo and ataxia are markedly reduced or abolished by the administration of acetazolamide This

process is most likely related to the inherited acetazolamideresponsive ataxic syndrome described in Chap 5 A form that is kinesogenic, ie, brought on by activity, has a similar appearance In summary, the nature of the nystagmus, instability of the eyes during the head impulse test, and the other features of the neurologic examination allow a distinction to be made between central and peripheral cases of vertigo Associated hearing loss favors a vestibular cause of vertigo The features of the various vertiginous syndromes are summarized in Table 15-2

an existing query or formulate a new query with which the appropriate view of the data can be created I learned the hard way that failing to follow this procedure that is, specifying the chart type to display before publishing the chart wastes a lot of time Instead of identifying the format of the chart first and then building the query to the appropriate view, I would create the query first and then force the chart type to fit my query structure I do not recommend this approach As you can see, the charts that you normally work with are in classes 1 and 2 primarily (but I have run into the waterfall chart type in a number of projects) As long as you are comfortable working with class 1 and 2 chart types, you should be able to support over 85 percent of your customers needs Most of the charts listed in Table 6-2 can be displayed with various dimensions, such as 2 dimensions, 25 dimensions (limited three-dimensionality), and 3D (regular threedimensionality) Bar and column charts can be converted into pyramid, cone, or cylinder diagrams in 25D and 3D mode The dimensional look and feel of the charts is a good nice to have but, depending on the amount of information and data points on the chart, the 3D format may be more distracting than useful I recommend using the 3D format only if the customer requests it Another variant that exists for line, column, bar, profile, and radar charts is a stacked variant These values of the data series are added and displayed on top of one another in a category and normally are differentiated by colors Stacked charts display the relationship between individual elements and the total of all values You can also set 100% variants for line, profile, column, bar, area, and profile charts The sum of all data series in a category is 100 percent The values of individual data series are converted into percentage values and displayed accordingly.

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