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Lesions of the cerebellum produce vertigo depending on which part of this structure is involved Large, destructive processes in the cerebellar hemispheres and vermis such as cerebellar hemorrhage may, or at times may not, cause vertigo However, strokes in the territory of the medial branch of the posterior inferior cerebellar artery (which arises distal to the branches to the medulla and therefore does not involve the lateral medulla) may cause intense vertigo and vomiting that is indistinguishable from that due to labyrinthine disorder In two such pathologically studied cases, a large zone of infarction extended to the midline and involved the occulonodular lobe (Duncan et al) Falling in these cases was toward the side of the lesion; nystagmus was present on gaze to each side but was more prominent on gaze to the side of the infarct These ndings have been con rmed by computed tomography (CT) and magnetic resonance imaging (MRI) (Amarenco et al) Labyrinthine disease, on the other hand, causes predominantly unidirectional nystagmus to the side opposite the impaired labyrinth and swaying or falling toward the involved side i,e, the direction of the nystagmus is opposite to that of the falling and past pointing (the latter referring to overshooting a target by the patient s nger with eyes closed, as originally described by Barany) Early in the course of an acute attack of vertigo, when it may be dif cult to assess the gait and the quality of nystagmus, it is necessary to exclude a cerebellar infarct or hemorrhage by use of imaging procedures Biemond and DeJong described a kind of nystagmus and vertigo originating in the upper cervical roots and the muscles and ligaments that they innervate (so-called cervical vertigo) Spasm of the cervical muscles, trauma to the neck, and irritation of the upper cervical sensory roots were said to produce asymmetrical spinovestibular stimulation and thus to evoke nystagmus, prolonged vertigo, and disequilibrium Cervical vertigo has also been attributed, on very uncertain grounds, to circulatory insuf ciency in the vertebrobasilar territory Toole and Tucker demonstrated a reduced ow through these vessels (in cadavers) when the head was rotated or hyperextended In our view, the existence of cervical vertigo, or at least these interpretations of it, is still open to question However, we must acknowledge having encountered patients with cervical dystonia who describe something akin to vertigo, and this may speak to a relationship between cervical proprioceptors and vertigo Causes of vertigo other than Meniere disease that originate in ` the vestibular nerve are discussed further on In summary, although lesions of the cerebral cortex, eyes, and perhaps the cervical muscles may give rise to vertigo, they are not common sources of the symptom, and vertigo is rarely the dominant manifestation of disease in these parts For all practical purposes, vertigo indicates a disorder of the vestibular end organs, the vestibular division of the eighth nerve, or the vestibular nuclei in the brainstem and their immediate connections, including the inferior cerebellum The clinical problem resolves itself into deciding which portion of the labyrinthine-vestibular apparatus is primarily involved Usually this decision can be made on the basis of the form of the vertiginous attack, the nature of the ancillary symptoms and signs, and tests of labyrinthine function The latter are described below, followed by a description of the common labyrinthine-vestibular syndromes.

In binary this is particularly easy since each intermediate row is either zero or x itself, leftshifted an appropriate amount of times Also notice that left-shifting is just a quick way to multiply by the base, which in this case is 2 (Likewise, the effect of a right shift is to divide by the base, rounding down if needed) The correctness of this multiplication procedure is the subject of Exercise 16; let s move on and gure out how long it takes If x and y are both n bits, then there are n intermediate 21

The most rudimentary test of labyrinthine function is simply to have the patient shake his head from side-to-side in an attempt to

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elicit symptoms that simulate the dizziness that has been described and to observe the degree of postural instability during this maneuver Falling and marked intensi cation of the dizziness is almost always an indication of labyrinthine disease Also, nystagmus may be evoked, indicating a vestibular instability More informative is the rapid head impulse test, which is conducted by asking the patient to xate on a target and then for the examiner to quickly rotate the patient s head by 10 degrees (an explanation must be given to encourage the patient to relax the neck muscles and remain focused on the xation point) The eyes are observed for a slippage from the target; this is most evident by a quick saccadic return to the point of focus Ocular instability is elicited when the patient turns his head toward the side of the affected labyrinth This use of the vestibulo-ocular re ex is said by Halmagyi to be among the most dependable bedside tests of labyrinthine function Maneuvers designed to elicit positional vertigo by rapidly changing from a seated to a supine position with the head turned to one side bring about vertigo in a number of conditions but are speci cally intended to detect so-called benign positional vertigo and are described further on A number of other interesting but unvalidated tests that bring out instabilities in station and gait may be used to supplement the conventional tests for vestibular dysfunction The Unterberger maneuver requires the patient to march in place with eyes closed and arms outstretched Normally, less than 15 degrees or so of rotation is displayed; asymmetry of labyrinthine function is manifest as excessive rotation away from the diseased side A related test attributed to Fukada involves having the patient walk around a chair with eyes closed; an increasing or decreasing radius is indicative of an imbalance between the two sides of the labyrinthine apparatus Both of these tests, however, often show abnormalities with cerebellar disease as well, and the sensitivity of maneuvers such as these has been questioned We can only comment that they seem in our experience to demonstrate vestibulocerebellar lesions but are no more helpful than other less elaborate bedside investigations Irrigation of the ear canal alternately with cold and warm water (caloric or oculovestibular testing) may be used to disclose a reduction in labyrinthine function in the form of an impairment or loss of thermally induced nystagmus on the involved side In caloric testing, the patient s head is ideally tilted forward 30 degrees from the horizontal; this brings the horizontal semicircular canal into a vertical plane, the position of maximal sensitivity of this canal to thermal stimuli Each external auditory canal is irrigated for 30 s, rst with water at 30 C and then at 44 C (7 C below and above body temperature), with a pause of at least 5 min between each irrigation In normal persons, cold water induces a slight tonic deviation of the eyes to the side being irrigated, followed, after a latent period of about 20 s, by nystagmus to the opposite side (direction of the fast phase) Warm water induces nystagmus to the irrigated side (As noted in Chap 14, this is the basis for the mnemonic COWS : cold opposite, warm same, referring to the direction of compensatory nystagmus) In normal subjects, the nystagmus usually persists for 90 to 120 s, although the range is considerably larger Nausea and symptoms of excessive re ex vagal activity may occur in sensitive individuals Simultaneous irrigation of both canals with cold water causes a tonic downward deviation of the eyes, with nystagmus (quick component) upward Bilateral irrigation with warm water yields a tonic upward movement and nystagmus in the opposite direction Caloric testing will reliably answer whether the vestibular end organs react, and comparison of the responses from the two ears will.

` Figure 11 Multiplication a la Francais function multiply(x, y) Input: Two n-bit integers x and y, where y 0 Output: Their product if y = 0: return 0 z = multiply(x, y/2 ) if y is even: return 2z else: return x + 2z

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