Vertigo

Contents1 Background2 Clinical Features2.1 Classification[1]2.2 Central vs. Peripheral Causes of Vertigo3 Differential Diagnosis3.1 Vertigo4 Evaluation4.1 Work-up4.2 HINTS Exam4.2.1 Inclusion Criteria4.2.2 The 3 components of the HINTS exam include:4.2.3 Head Impulse Test4.2.4 Nystagmus4.2.5 Test of Skew5 Management5.1 Peripheral5.1.1 Symptomatic control5.1.2 Cause Reversal5.2 Central6 Disposition7 See Also8 ReferencesBackgroundPerception of movement (rotational or otherwise) where no movement existsDon't assume that persistent vertigo that worsens with movement is benign; central vertigo may also worsen with movementPathophysiologyMismatch or asymmetric activity of visual, vestibular, and/or proprioceptive systemsEvaluation should focus on determining whether the etiology is peripheral or central, with a secondary focus on diagnosisPeripheral: 8th CN, vestibular apparatusCentral: Brainstem, cerebellumMany clinicians ask about presence of "room-spinning" sensation to distinguish lightheadedness vs vertigo, but this distinction may be of limited usefulnessThe ATTEST mnemonic can be helpful: Associated symptoms, Timing, Triggers, Exam Signs and TestingVital for triaging benign vs dangerous conditions (see Clinical features)In any vertigo presentation, consider nonvertiginous causes such as presyncope, which may be medication-induced in a polypharmacy patient populationAlways take a full medication historyClinical FeaturesClassification[1]Triggered episodic vestibular syndromeTriggered by movement (change in body position, head mvmt, valsalva)Lasts sec to minute/hours with asymptomatic periods in betweenBenign:BPPV (Dix Hallpike), orthostatic hypotension (fluids), medication-induced effectsDangerous: Posterior Fossa TumorSpontaneous episodic vestibular syndromeDistinct onset, but without a clear position/motion-induced triggerLasts min to hoursTypically asymptomatic on presentationBenign: Anxiety, vasovagal syncope, Meniere's, vestibular MigraineDangerous: TIA, arrhythmia, PEAcute Vestibular Syndrome (AVS)Abrupt and persistentCan be exacerbated by movement but not triggered by it (i.e. symptoms persist at rest & exacerbated with movement)Benign: Vestibular Neuritis, LabyrinthitisDangerous: Posterior StrokeUtilize HINTS Exam to differentiateRemember, the HINTS Exam can only be used on symptomatic AVS patients according to the study[2]Central vs. Peripheral Causes of VertigoPeripheralCentralOnsetSuddenSudden or slowSeverityIntense spinningIll defined, less intensePatternParoxysmal, intermittentConstantAggravated by position/movementYesVariableNausea/diaphoresisFrequentVariableNystagmusHorizontal and unidirectionalVertical and/or multidirectionalFatigue of symptoms/signsYesNoHearing loss/tinnitusMay occurDoes not occurAbnormal tympanic membraneMay occurDoes not occurCNS symptoms/signsAbsentUsually presentDifferential DiagnosisVertigoVestibular/otologicBenign paroxysmal positional vertigo (BPPV)Traumatic (following head injury)InfectionLabyrinthitisVestibular neuritisRamsay Hunt syndromeMénière's diseaseEar foreign bodyOtic barotraumaOtosclerosisNeurologicCerebellar strokeVertebrobasilar insufficiencyLateral Wallenberg syndromeAnterior inferior cerebellar artery syndromeNeoplastic: cerebellopontine angle tumorsBasal ganglion diseasesVertebral Artery DissectionMultiple sclerosisInfections: neurosyphilis, tuberculosisEpilepsyMigraine (basilar)OtherHematologic: anemia, polycythemia, hyperviscosity syndromeToxicAlcoholAminoglycosidesChronic renal failureMetabolicThyroid DiseaseHypoglycemiaEvaluationWork-up

Diagnostic algorithm VertigoGlucose checkFull neuro examTM examCTA or MRA (diagnostic study of choice) of the neck/brain if symptoms consistent with central causeTestSensitivityHINTS100%MRI (24hrs)68.40%[3]MRI (48hrs)81%[3]CT non con26%[4]HINTS Exam

Proposed as method of distinguishing peripheral cause from cerebellar/brain stem CVA in the Emergency Department population. [5][6][7]Only to be used in patients with persistent dizziness, not those with resolved symptoms.

Inclusion CriteriaHINTS exam should only be used in patient with acute persistent vertigo, nystagmus, and a normal neurological exam.HINTS exam, when done correctly, has high sensitivity and specificity in distinguishing peripheral vs central etiologies of vertigoNote that the original study was done by neuro-ophthalmologists in a differentiated patient base. This exam has not been studied in a large ED population yetThe 3 components of the HINTS exam include:HINTS TestReassuring FindingHead Impulse TestAbnormal (corrective saccade)NystagmusUnidirectional, horizontalTest of SkewNo skew deviationAlways use correct terminology; "HINTS negative" does not convey a clear interpretation. State "HINTS central" or "HINTS peripheral" as suggested in literatureIf able, specify the exact exam finding as shown by chart aboveHead Impulse Test

Test of vestibulo-ocular reflex function

Have patient fix their eyes on your noseMove their head rapidly in the horizontal plane to the left and rightWhen the head is turned towards the normal side, the vestibular ocular reflex remains intact and eyes continue to fixate on the visual targetWhen the head is turned towards the affected side, the vestibular ocular reflex fails and the eyes make a visible corrective saccade to re-fixate on the visual target [8][9]Normally, a functional vestibular system will identify any movement of the head position and instantaneously correct eye movement accordingly so that the center of the vision remains on a target.This reflex fails in peripheral causes of vertigo affecting the vestibulocochlear nerve unilaterally; thus, failure of the reflex unilaterally is reassuring (since the cause is peripheral)Note that in central causes of vertigo, test may show normal reflex response OR failure of the reflex BILATERALLYNystagmusObservation for nystagmus in primary, right, and left gazeNo nystagmus (normal) or only horizontal unilateral nystagmus (fast direction only in one direction) is reassuringAny other type of nystagmus is abnormal, including vertical or bidirectional nystagmusTest of SkewHave patient look at your nose with their eyes and then cover one eyeThen rapidly uncover the eye and quickly look to see if the eye moves to re-align.Repeat with on each eyeSkew deviation is a fairly specific predictor of brainstem involvement in patients with acute vestibular syndrome. The presence of skew may help identify stroke when a positive head impulse test falsely suggests a peripheral lesion.Skew is also known vertical dysconjugate gaze and is a sign of a central lesionA positive HINTS exam: 100% sensitive and 96% specific for the presence of a central lesion.The HINTS exam was more sensitive than general neurological signs: 100% versus 51%.The sensitivity of early MRI with DWI for lateral medullary or pontine stroke was lower than that of the HINTS examination (72% versus 100%, P=0.004) with comparable specificity (100% versus 96%, P=1.0).If any of the above 3 tests are consistent with CVA obtain full work-up (including MRI)ManagementPeripheralSymptomatic controlAntihistamines: inhibit vestibular stimulation and vestibular-cerebellar pathwaysMeclizine (Antivert) 25mg PO QIDDiphenhydramine (Benadryl) 25-50mg IM, IV, or PO q4hrAnticholinergicsScopolamine transdermal patch 0.5mg (behind ear) QIDAntidopaminergicsMetoclopramide 10-20 IV or PO TIDBenzodiazepinesDiazepam 2.5-10 mg q6h PRNuse with caution in elderly populationCause ReversalEpley maneuver (see BPPV)CentralRule out CVAMRIRule out vascular insufficiencyDispositionMost patients with peripheral vertigo can be discharged homeAll patients with central vertigo require urgent imaging and consultation while in the EDPrior to discharge, a trial of ambulation should be attempted:A peripheral vestibular lesion generally produces unidirectional postural instability with preserved walkingAn inferior cerebellar stroke often causes severe postural instability and fallingSee AlsoDizzinessEBQ:HINTS_ExamCerebellar StrokeStroke syndromesReferences↑ Edlow JA, Newman-Toker D. Using the Physical Exam to Diagnose Patients with Acute Dizziness and Vertigo. J Emerg Med. 2016 Apr 50(4): 617-28.↑ Kattah, J. et al. "HINTS to Diagnose Stroke in the Acute Vestibular Syndrome: Three-Step Bedside Oculomotor Examination More Sensitive Than Early MRI Diffusion-Weighted Imaging". Stroke. 2009. 40(11):3504–3510.↑ 3.0 3.1 http://www.cnsuwo.ca/ebn/downloads/cats/2010/CNS-EBN_cat-document_2010-07-JUL-30_a-negative-dwi-mri-within-48-hours-of-stroke-symptoms-ruled-out-anterior-circulation-stroke_4494E.pdf↑ Chalela JA, Kidwell CS, Nentwich LM, et al. Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison. Lancet. 2007;369:293–8.↑ http://ec.libsyn.com/p/a/d/d/add761f2a2847ea5/hints-exam.pdf?d13a76d516d9dec20c3d276ce028ed5089ab1ce3dae902ea1d01c0873ed8cc5fe910&c_id=2502227↑ http://www.ncbi.nlm.nih.gov/pubmed/18541870↑ http://hwcdn.libsyn.com/p/1/c/d/1cd6b38a89c178a1/diff-of-vertigo.pdf?c_id=2502226&expiration=1380995436&hwt=0a8bc67ea910e018a1543ebea192f668↑ Barraclough K, Bronstein A. Vertigo. BMJ. 2009;339:b3493↑ Kuo CH, Pang L, Chang R. Vertigo - part 1 - assessment in general practice. Aust Fam Physician. 2008;37(5):341-7

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Vertigo

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