Vertigo

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

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 Vertical 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

Diagnosis

Algorithm

Vertigo and Dizziness.jpg

HINTS Exam

Can reliably^ distinguish peripheral cause from cerebellar/brain stem CVA in the Emergency Department population [1][2][3]

  1. Head Impulse Testing
    1. Tests vestibulo-ocular reflex
    2. Have pt fix their eyes on your nose
    3. Move their head in the horizontal plane to the left and right
      1. If reflex is intact their eyes will stay fixed on your nose
      2. If reflex is abnormal eyes will move w/ their head and won't stay fixed on your nose
    4. It is reassuring if the reflex is abnormal!(due to dysfunction of the nerve)
  2. Nystagmus
    1. Benign nystagmus only beats in one direction no matter which direction their eyes look
    2. Bad nystagums beats in every direction their eyes look
      1. If pt looks left, get left nystagmus, if looks right, get right-beating nystagmus
  3. Test of Skew
    1. Vertical dysconjugate gaze is bad
    2. Alternating cover test
      1. Have pt look at your nose w/ their eyes and then cover one eye
      2. When rapidly uncover the eye look to see if the eye quickly moves to re-align
    3. If any of the above 3 tests are consistent w/ CVA obtain full work-up (including MRI)

^Sensitivity (for posterior ischemic CVA):

  • HINTS = 100%?
  • MRI <48hrs after symptom onset = 83%
  • MRI >48hrs = 100%?
  • CT = 16%

^Positive test = INFARCT for posterior stroke

  • Impulse Normal (abnormal indicates peripheral)
  • Fast-phase Alternates (saccades alternate direction)
  • Refixation on Cover Test

DDX

  1. Vestibular/otologic
    1. Benign Paroxysmal Positional Vertigo (BPPV)
    2. Traumatic (following head injury)
    3. Infection
      1. Labyrinthitis
      2. Vestibular Neuritis (Neuronitis)
      3. Ramsay Hunt syndrome
  2. Syndrome
    1. Meniere Disease
    2. Neoplastic
    3. Vascular
    4. Otosclerosis
    5. Paget disease
    6. Toxic or drug-induced: aminoglycosides
  3. Neurologic
    1. Vertebrobasilar insufficiency
      1. Head turning causes vertigo, diplopia, dysarthria, b/l loss of vision, syncope
    2. Lateral Wallenberg syndrome
    3. Anterior inferior cerebellar artery syndrome
    4. Neoplastic: cerebellopontine angle tumors
    5. Cerebellar disorders: hemorrhage, degeneration
    6. Basal ganglion diseases
    7. Multiple sclerosis
    8. Infections: neurosyphilis, tuberculosis
    9. Epilepsy
    10. Migraine (basilar)
    11. Cerebrovascular disease
  4. General
    1. Hematologic: anemia, polycythemia, hyperviscosity syndrome
    2. Toxic: alcohol
    3. Chronic renal failure
    4. Metabolic
      1. Thyroid Disease
      2. Hypoglycemia

Work-up

  1. Glucose check
  2. Full neuro exam
  3. TM exam
  4. ?CT/MRI - if symptoms consistent with central cause

Management

Peripheral

Symptomatic control

  1. Antihistamines
    1. Meclizine (antivert) 25mg PO QID
    2. Diphenhydramine (benadryl) 25-50mg IM, IV, or PO q4hr
  2. Anticholinergics
    1. Scopolamine transdermal patch 0.5mg (behind ear) QID
  3. Antidopaminergics
    1. Metoclopramide 10-20 IV or PO TID

Cause Reversal

  1. Epley maneuver (see BPPV)

Central

  1. R/O CVA
  2. MRI
  3. R/O Vascular insufficiency

Disposition

  • Most pts w/ peripheral vertigo can be discharged home
  • Most pts w/ central vertigo require urgent imaging and consultation while in the ED

See Also

Source

  • Tintinalli
  1. ↑ http://ec.libsyn.com/p/a/d/d/add761f2a2847ea5/hints-exam.pdf?d13a76d516d9dec20c3d276ce028ed5089ab1ce3dae902ea1d01c0873ed8cc5fe910&c_id=2502227
  2. ↑ http://www.ncbi.nlm.nih.gov/pubmed/18541870
  3. ↑ http://hwcdn.libsyn.com/p/1/c/d/1cd6b38a89c178a1/diff-of-vertigo.pdf?c_id=2502226&expiration=1380995436&hwt=0a8bc67ea910e018a1543ebea192f668
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