Vertigo

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Background

  • Perception of movement (rotational or otherwise) where no movement exists
  • Pathophysiology
    • Mismatch or asymmetric activity of visual, vestibular, and/or proprioceptive systems
  • Must distinguish peripheral from central cause
    • Peripheral: 8th CN, vestibular apparatus
    • Central: Brainstem, cerebellum

Clinical Features

Classification[1]

  • Triggered Vestibular Syndrome
    • Triggered by movement (change in body position, head mvmt, valsalva)
    • Lasts sec to hours w/ asymptomatic periods in between
    • Benign:BPPV (Dix Hallpike), Orthostatic Hypotension (fluids)
    • Dangerous: Posterior Fossa Tumor
  • Episodic Vestibular Syndrome
    • Distinct onset
    • Lasts min to hours
    • Typically asymptomatic on presentation
    • Benign: Anxiety, vasovagal syncope, Meniere's
    • Dangerous: TIA, arrythmia, PE

Central vs. Peripheral Causes of Vertigo

Peripheral Central
Onset Sudden Sudden or slow
Severity Intense spinning Ill defined, less intense
Pattern Paroxysmal, intermittent Constant
Aggravated by position/movement Yes Variable
Nausea/diaphoresis Frequent Variable
Nystagmus Horizontal and unidirectional Vertical and/or multidirectional
Fatigue of symptoms/signs Yes No
Hearing loss/tinnitus May occur Does not occur
Abnormal tympanic membrane May occur Does not occur
CNS symptoms/signs Absent Usually present

Differential Diagnosis

Vertigo

Evaluation

Work-up

Diagnostic algorithm Vertigo
  1. Glucose check
  2. Full neuro exam
  3. TM exam
  4. CTA or MRA (diagnostic study of choice) of the neck/brain if symptoms consistent with central cause
Test Sensitivity
HINTS 100%
MRI (24hrs) 68.40%[3]
MRI (48hrs) 81%[3]
CT non con 26%[4]

HINTS Exam

Proposed as method of distinguishing peripheral cause from cerebellar/brain stem CVA in the Emergency Department population [5][6][7]

The 3 components of the HINTS exam include:

  1. Head impulse test of vestibulo-ocular reflex function
  2. Observation for nystagmus in primary, right, and left gaze
  3. Alternate cover test for skew deviation.

Head Impulse Test:

  1. Normally, a functional vestibular system will identify any movement of the head position and rapidly correct eye movement accordingly so that the center of the vision remains on a target. This reflex fails in peripheral causes of vertigo effective the vestibulocochlear nerve
  2. Have patient fix their eyes on your nose
  3. Move their head in the horizontal plane to the left and righ
  4. When the head is turned towards the normal side the vestibular ocular reflex remains intact and eyes continue to fixate on the visual target
  5. When the head is turned towards the affected side, the vestibular ocular reflex fails and the eyes make a corrective saccade to re-fixate on the visual target [8][9]
  6. It is reassuring if the reflex is abnormal (due to dysfunction of the peripheral nerve)

Test of Skew

  • Skew 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 lesion
  1. Have pt look at your nose with their eyes and then cover one eye
  2. Then rapidly uncover the eye and quickly look to see if the eye moves to re-align.
  3. Repeat with on each eye
  • A 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)

Management

Peripheral

Symptomatic control

  1. Antihistamines: inhibit vestibular stimulation and vestibular-cerebellar pathways
  2. Anticholinergics
    • Scopolamine transdermal patch 0.5mg (behind ear) QID
  3. Antidopaminergics
    • Metoclopramide 10-20 IV or PO TID

Cause Reversal

  1. Epley maneuver (see BPPV)

Central

  • R/O CVA
  • MRI
  • R/O Vascular insufficiency

Disposition

  • Most patients with peripheral vertigo can be discharged home
  • All patients with central vertigo require urgent imaging and consultation while in the ED

See Also

References

  1. 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.
  2. 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. 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
  4. 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.
  5. http://ec.libsyn.com/p/a/d/d/add761f2a2847ea5/hints-exam.pdf?d13a76d516d9dec20c3d276ce028ed5089ab1ce3dae902ea1d01c0873ed8cc5fe910&c_id=2502227
  6. http://www.ncbi.nlm.nih.gov/pubmed/18541870
  7. http://hwcdn.libsyn.com/p/1/c/d/1cd6b38a89c178a1/diff-of-vertigo.pdf?c_id=2502226&expiration=1380995436&hwt=0a8bc67ea910e018a1543ebea192f668
  8. Barraclough K, Bronstein A. Vertigo. BMJ. 2009;339:b3493
  9. Kuo CH, Pang L, Chang R. Vertigo - part 1 - assessment in general practice. Aust Fam Physician. 2008;37(5):341-7