Vertigo: Difference between revisions
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== Background == | ==Background== | ||
*Perception of movement (rotational or otherwise) where no movement exists | *Perception of movement (rotational or otherwise) where no movement exists | ||
**Don't assume that persistent vertigo that worsens with movement is benign; central vertigo may also worsen with movement | |||
*Pathophysiology | *Pathophysiology | ||
**Mismatch or asymmetric activity of visual, vestibular, and/or proprioceptive systems | **Mismatch or asymmetric activity of visual, vestibular, and/or proprioceptive systems | ||
* | *Evaluation should focus on determining whether the etiology is peripheral or central, with a secondary focus on diagnosis | ||
**Peripheral: 8th CN, vestibular apparatus | **Peripheral: 8th CN, vestibular apparatus | ||
**Central: Brainstem, cerebellum | **Central: Brainstem, cerebellum | ||
**Many clinicians ask about presence of "room-spinning" sensation to distinguish lightheadedness vs vertigo, but this distinction may be of limited usefulness | |||
*The '''ATTEST''' mnemonic can be helpful: '''A'''ssociated symptoms, '''T'''iming, '''T'''riggers, '''E'''xam '''S'''igns and '''T'''esting | |||
**Vital 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 population | |||
**Always take a full medication history | |||
== Clinical Features== | ==Clinical Features== | ||
===Classification<ref>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.</ref>=== | |||
*Triggered episodic vestibular syndrome | |||
**Triggered by movement (change in body position, head mvmt, valsalva) | |||
**Lasts sec to minute/hours with asymptomatic periods in between | |||
**Benign:[[BPPV]] (Dix Hallpike), orthostatic [[hypotension]] (fluids), medication-induced effects | |||
**Dangerous: Posterior Fossa [[brain tumor|Tumor]] | |||
*Spontaneous episodic vestibular syndrome | |||
**Distinct onset, but without a clear position/motion-induced trigger | |||
**Lasts min to hours | |||
**Typically asymptomatic on presentation | |||
**Benign: [[Anxiety]], vasovagal syncope, [[Meniere%27s_disease|Meniere's]], vestibular [[Migraine]] | |||
**Dangerous: [[TIA]], [[arrhythmia]], [[PE]] | |||
| ' | |||
*Acute Vestibular Syndrome (AVS) | |||
**Abrupt and persistent | |||
[[ | **Can be exacerbated by movement but not triggered by it (i.e. symptoms persist at rest & exacerbated with movement) | ||
**Benign: [[Vestibular Neuritis]], [[Labyrinthitis]] | |||
**Dangerous: [[Stroke|Posterior Stroke]] | |||
**Utilize [[EBQ:HINTS_Exam|HINTS Exam]] to differentiate | |||
***Remember, the [[EBQ:HINTS_Exam|HINTS Exam]] can only be used on symptomatic AVS patients according to the study<ref>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.</ref> | |||
{{Central vs. peripheral causes of vertigo table}} | |||
==Differential Diagnosis== | |||
{{Vertigo DDX}} | |||
==Evaluation== | |||
{{Vertigo workup}} | |||
== | ===[[EBQ: HINTS Exam|HINTS Exam]]=== | ||
Proposed as method of distinguishing peripheral cause from cerebellar/brain stem CVA in the Emergency Department population. <ref>http://ec.libsyn.com/p/a/d/d/add761f2a2847ea5/hints-exam.pdf?d13a76d516d9dec20c3d276ce028ed5089ab1ce3dae902ea1d01c0873ed8cc5fe910&c_id=2502227</ref><ref>http://www.ncbi.nlm.nih.gov/pubmed/18541870</ref><ref>http://hwcdn.libsyn.com/p/1/c/d/1cd6b38a89c178a1/diff-of-vertigo.pdf?c_id=2502226&expiration=1380995436&hwt=0a8bc67ea910e018a1543ebea192f668</ref> | |||
Only to be used in patients with persistent dizziness, not those with resolved symptoms. | |||
{{HINTS Exam Procedure}} | |||
{{HINTS Exam Primary Outcome}} | |||
*''If any of the above 3 tests are consistent with CVA obtain full work-up (including MRI)'' | |||
==Management== | ==Management== | ||
=== Peripheral === | ===Peripheral=== | ||
Symptomatic control | ====Symptomatic control==== | ||
*[[Antihistamines]]: inhibit vestibular stimulation and vestibular-cerebellar pathways | |||
**[[Meclizine]] (Antivert) 25mg PO QID | |||
**[[Diphenhydramine]] (Benadryl) 25-50mg IM, IV, or PO q4hr | |||
*[[Anticholinergics]] | |||
**[[Scopolamine]] transdermal patch 0.5mg (behind ear) QID | |||
*Antidopaminergics | |||
**[[Metoclopramide]] 10-20 IV or PO TID | |||
*Benzodiazepines | |||
**[[Diazepam]] 2.5-10 mg q6h PRN | |||
**use with caution in elderly population | |||
Cause Reversal | ====Cause Reversal==== | ||
*Epley maneuver (see [[BPPV]]) | |||
===Central=== | ===Central=== | ||
*Rule out [[CVA]] | |||
*[[brain MRI|MRI]] | |||
*Rule out [[vertebrobasilar insufficiency|vascular insufficiency]] | |||
== Disposition == | ==Disposition== | ||
*Most | *Most patients with peripheral vertigo can be discharged home | ||
* | *All patients with central vertigo require urgent imaging and consultation while in the ED | ||
*Prior to discharge, a trial of ambulation should be attempted: | |||
**A peripheral vestibular lesion generally produces unidirectional postural instability with preserved walking | |||
**An inferior cerebellar stroke often causes severe postural instability and falling | |||
==See Also== | ==See Also== | ||
Line 163: | Line 90: | ||
*[[Stroke syndromes]] | *[[Stroke syndromes]] | ||
== | ==References== | ||
<references/> | <references/> | ||
[[Category: | [[Category:Neurology]] | ||
[[Category:Featured]] | |||
[[Category:Symptoms]] |
Latest revision as of 20:12, 17 April 2024
Background
- Perception of movement (rotational or otherwise) where no movement exists
- Don't assume that persistent vertigo that worsens with movement is benign; central vertigo may also worsen with movement
- Pathophysiology
- Mismatch or asymmetric activity of visual, vestibular, and/or proprioceptive systems
- Evaluation should focus on determining whether the etiology is peripheral or central, with a secondary focus on diagnosis
- Peripheral: 8th CN, vestibular apparatus
- Central: Brainstem, cerebellum
- Many clinicians ask about presence of "room-spinning" sensation to distinguish lightheadedness vs vertigo, but this distinction may be of limited usefulness
- The ATTEST mnemonic can be helpful: Associated symptoms, Timing, Triggers, Exam Signs and Testing
- Vital 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 population
- Always take a full medication history
Clinical Features
Classification[1]
- Triggered episodic vestibular syndrome
- Triggered by movement (change in body position, head mvmt, valsalva)
- Lasts sec to minute/hours with asymptomatic periods in between
- Benign:BPPV (Dix Hallpike), orthostatic hypotension (fluids), medication-induced effects
- Dangerous: Posterior Fossa Tumor
- Spontaneous episodic vestibular syndrome
- Acute Vestibular Syndrome (AVS)
- Abrupt and persistent
- Can be exacerbated by movement but not triggered by it (i.e. symptoms persist at rest & exacerbated with movement)
- Benign: Vestibular Neuritis, Labyrinthitis
- Dangerous: Posterior Stroke
- Utilize HINTS Exam to differentiate
- Remember, the HINTS Exam can only be used on symptomatic AVS patients according to the study[2]
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
- Vestibular/otologic
- Benign paroxysmal positional vertigo (BPPV)
- Traumatic (following head injury)
- Infection
- Ménière's disease
- Ear foreign body
- Otic barotrauma
- Otosclerosis
- Neurologic
- Cerebellar stroke
- Vertebrobasilar insufficiency
- Lateral Wallenberg syndrome
- Anterior inferior cerebellar artery syndrome
- Neoplastic: cerebellopontine angle tumors
- Basal ganglion diseases
- Vertebral Artery Dissection
- Multiple sclerosis
- Infections: neurosyphilis, tuberculosis
- Epilepsy
- Migraine (basilar)
- Other
- Hematologic: anemia, polycythemia, hyperviscosity syndrome
- Toxic
- Chronic renal failure
- Metabolic
Evaluation
Work-up
- Glucose check
- Full neuro exam
- TM exam
- 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] Only to be used in patients with persistent dizziness, not those with resolved symptoms.
Inclusion Criteria
- HINTS 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 vertigo
- Note 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 yet
The 3 components of the HINTS exam include:
HINTS Test | Reassuring Finding |
Head Impulse Test | Abnormal (corrective saccade) |
Nystagmus | Unidirectional, horizontal |
Test of Skew | No skew deviation |
- Always use correct terminology; "HINTS negative" does not convey a clear interpretation. State "HINTS central" or "HINTS peripheral" as suggested in literature
- If able, specify the exact exam finding as shown by chart above
Head Impulse Test
Test of vestibulo-ocular reflex function
- Have patient fix their eyes on your nose
- Move their head rapidly in the horizontal plane to the left and right
- When the head is turned towards the normal side, the vestibular ocular reflex remains intact and eyes continue to fixate on the visual target
- When 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 BILATERALLY
Nystagmus
- Observation for nystagmus in primary, right, and left gaze
- No nystagmus (normal) or only horizontal unilateral nystagmus (fast direction only in one direction) is reassuring
- Any other type of nystagmus is abnormal, including vertical or bidirectional nystagmus
Test of Skew
- Have patient look at your nose with their eyes and then cover one eye
- Then rapidly uncover the eye and quickly look to see if the eye moves to re-align.
- Repeat with on each eye
- 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
- 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
- Antihistamines: inhibit vestibular stimulation and vestibular-cerebellar pathways
- Meclizine (Antivert) 25mg PO QID
- Diphenhydramine (Benadryl) 25-50mg IM, IV, or PO q4hr
- Anticholinergics
- Scopolamine transdermal patch 0.5mg (behind ear) QID
- Antidopaminergics
- Metoclopramide 10-20 IV or PO TID
- Benzodiazepines
- Diazepam 2.5-10 mg q6h PRN
- use with caution in elderly population
Cause Reversal
- Epley maneuver (see BPPV)
Central
- Rule out CVA
- MRI
- Rule out 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
- Prior to discharge, a trial of ambulation should be attempted:
- A peripheral vestibular lesion generally produces unidirectional postural instability with preserved walking
- An inferior cerebellar stroke often causes severe postural instability and falling
See Also
References
- ↑ 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