Dizziness and Vertigo

Shawn Stepp, PA-CCentral Maine Medical CenterEmergency Department

Dizziness and VertigoPrimary resources: •Kattah, Talkad, Newman-Toker, Wang, Hsieh. HINTS to diagnose Stroke in the Acute Vestibular Syndrome: Three-Step Bedside Oculomoter Examination More Sensitive than Early MRI DWI. Stroke 2009; 40;3504-3510•Nelson, JA. The Clinical Differentiation of Cerebellar Infarction from Common Vertigo Syndromes. Western Journal of Emerg Med Nov. 2009; vol x, no 4.•Asimos, Andrew, MD. THE DIZZY PATIENT. Lecture from the 38th Annual Michigan Emergency Medicine Assembly. •Kerber KA. Vertigo and Dizziness in the Emergency Department. Emerg Med Clin N Am 2009;27:39–50.

•Tarnutzer AA. Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome. CMAJ 2011;183(9) :E571-92.

Dizziness and VertigoWhen Dizzy is a Disaster: Cerebellar Stroke and vestibulobasilar insufficiency• Clinical presentation can resemble many other benign disorders• Main symptoms are non-specific Dizziness, N/V, headache• Important components of the neuro exam that help to make the

diagnosis commonly omitted or abridged in the ED and the family practice office

• Coordination, gait, and eye movement abnormalities can be subtle• Brain CT rarely identifies early-stage cerebellar infarction (only 26% of

the time)• Morbidity includes brainstem compression and obstructive

hydrocephalus

Dizziness and VertigoCase number 1

Dizziness and Vertigo• Video of Dix-hallpike:

https://www.youtube.com/watch?v=ZVCliBpcInw• Video of torsional upward beating nystagmus:

https://www.youtube.com/watch?v=rtS2muvjFbM

Dizziness and Vertigo

• Dix hallpike: hold head 45 degrees to one side. Lower quickly with head 10-30 degrees extended off the end of the bed.

• Results in BPPV: • torsional nystagmus generally upward beating and toward the side of

the semicirular canal problem. The nystagmus will occur when the affected ear is closest to the ground

• Latency of onset (usually 5–10 seconds, but can be up to 40 secs)• The nystagmus are fatigable (generally less than a minute)• Nystagmus often reverse direction/rotation when sitting up quickly

Modified Epley Maneuver

Dizziness and Vertigo• Benign Paroxysmal Positional Vertigo: Most common cause of

vertigo• Lifetime prevalence of 3.2% in females and 1.6% in males• Of 100 unselected elderly patients, a prevalence of 9% was

reported• Median duration of two weeks• Female preponderance likely reflects the association of migraine

with BPPV• Association of BPPV with hypertension and hyperlipidemia

• Von Brevern et al., 2006

Dizziness and VertigoCase number 2

What’s concerning about this patient?

Can’t walk. Diplopia

What’s the differential?

Cerebellar stroke, posterior circulation problem like vertebrobasilar insufficiency, labyrinthitis/vestibular neuritis, migrainous vertigo, and Meniere’s disease.

BPPV is not really in the differential as this is clearly not the diagnosis.

Dizziness and Vertigo

Dizziness and VertigoTrue, unrelenting vertigo= acute vestibular syndrome.

The HINTS test

HI=head impulseN= nystagmusTS= Test of skew

Dizziness and Vertigo• http://emcrit.org/misc/posterior-stroke-video/

NystagmusGood (peripheral cause) Bad (central cause likely)

Horizontal or rotational. Never purely vertical

Vertical (though can be horizontal)

Delayed onset with movement (5-40 secs)

Unrelenting

Inhibited by fixation Unrelenting

Fatigable Unrelenting

Unidirectional Direction changing (though can be unidirectional)

Dizziness and Vertigo• Test of Skew: Vertically disconjugate gaze. Pt looks at

examiner’s nose. If one eye drifts up or down, this is a positive test and likely indicates a central cause of the vertigo.

• Alternating cover test to vertical allignment: If the patient does not have an obvious vertically disconjugate gaze, cover one eye. Rapidly remove hand and watch to see if one eye realigns. Pt w/abnormal vertical skew often have Diplopia.

Dizziness and Vertigo

Emergent treatment: she woke up with the symptoms, so outside the potential treatment window for t-PA. So, ASA.Talk to neurology and this patient needs a MRI/MRA. Have to get the MRA portion to eval the vertebrobasilar vessels.

Small cerebellar stroke affecting the abduscens nucleus and the vestibular nucleus causing diplopia and gait instability. Thought to be likely embolic. She did well with rehab and PT. Plavix.

Head impulse normal and she had vertical skew deviation of her gaze.

Cerebellar and brainstem strokes• 3% of patients presenting to the ED with dizziness have a cerebellar

stroke.• 20% of all strokes are in the vertebrobasilar distribution• Grad and Baloh (1989): 62% had isolated vertigo without associated

neurological deficits, and 19% had isolated vertigo as first TIA• Several minutes (3-4 min) duration of vertigo and not provoked by

movement is always suspicious for TIA• These strokes can be devastating causing herniation and death. • They are often preceded by TIAs, represented by isolated vertigo, as

noted above• This does not mean that every dizzy patient gets an MRI/MRA.

Characteristics of VertigoDuration Etiology

Seconds BPPV

Minutes VBI, TIA

Hours Meniere’s

Days Vestibular Neuritis, Vertiginous Migraine, Brainstem or cerebellar stroke

Characteristics of VertigoGood (peripheral) Bad (likely central)Positional (provoked) Not positionalLasts less than a minute unless provoked again

Minutes to hours

No associated neurologic deficits (though 62% of strokes/TIAs also had no associated neuro deficits.

Neuro deficits (always do finger to nose, heal to shin, fine motor, etc.)

HI=abnormal N=rotational or horizontalTS=no vertical skew deviation

HI=normalN=vertical (though can be horizontal) TS=vertical skew deviation

Vertebrobasilar insufficiency

• Usually from atherosclerotic disease, but 1/5 of infarcts may be cardioembolic

• Causes episodic, spontaneus vertigo and neurologic symptoms (gait disturbance often) of abrupt onset in older patients that is often precipitated by a specific movement, likely extending the neck

Dizziness and Vertigo• Case 4

Dizziness and Vertigo

Nelson, JA. The Clinical Differentiation of Cerebellar Infarction from Common Vertigo Syndromes. Western Journal of Emerg Med Nov. 2009; vol x, no 4.

Dizziness and Vertigo

Nelson, JA. The Clinical Differentiation of Cerebellar Infarction from Common Vertigo Syndromes. Western Journal of Emerg Med Nov. 2009; vol x, no 4.

Vestibular Neuritis/Labyrinthitis

• Usually subacute in onset (increases over a few hours)• Remains at maximal intensity for 1-2 days.• Gradually resolves over a week or 2.• Can have hearing loss associated with it. Often have a preceeding

or current URI. May have tinnitus.• HI-markedly abnormal. Skew test normal .• Usually Viral cause• Treatment includes BZDs, other antiemetics (maybe meclizine),

and prednisone.

Dizziness and Vertigo• Test Limb AND trunkal ataxia. If they cannot walk appropriately,

must investigate further• Oculomotor testing (nystagmus especially). Diplopia is a bad sign• If positional vertigo: Dix-Hallpike and Epley• If acute vestibular syndrome, HINTS testing