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
HINTS Exam
Can reliably^ distinguish peripheral cause from cerebellar/brain stem CVA in the Emergency Department population [1][2][3]
- Head Impulse Testing
- Tests vestibulo-ocular reflex
- Have pt fix their eyes on your nose
- Move their head in the horizontal plane to the left and right
- If reflex is intact their eyes will stay fixed on your nose
- If reflex is abnormal eyes will move w/ their head and won't stay fixed on your nose
- It is reassuring if the reflex is abnormal!(due to dysfunction of the nerve)
- Nystagmus
- Benign nystagmus only beats in one direction no matter which direction their eyes look
- Bad nystagums beats in every direction their eyes look
- If pt looks left, get left nystagmus, if looks right, get right-beating nystagmus
- Test of Skew
- Vertical dysconjugate gaze is bad
- Alternating cover test
- Have pt look at your nose w/ their eyes and then cover one eye
- When rapidly uncover the eye look to see if the eye quickly moves to re-align
- 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
- Vestibular/otologic
- Benign Paroxysmal Positional Vertigo (BPPV)
- Traumatic (following head injury)
- Infection
- Labyrinthitis
- Vestibular Neuritis (Neuronitis)
- Ramsay Hunt syndrome
- Syndrome
- Meniere Disease
- Neoplastic
- Vascular
- Otosclerosis
- Paget disease
- Toxic or drug-induced: aminoglycosides
- Neurologic
- Vertebrobasilar insufficiency
- Head turning causes vertigo, diplopia, dysarthria, b/l loss of vision, syncope
- Lateral Wallenberg syndrome
- Anterior inferior cerebellar artery syndrome
- Neoplastic: cerebellopontine angle tumors
- Cerebellar disorders: hemorrhage, degeneration
- Basal ganglion diseases
- Multiple sclerosis
- Infections: neurosyphilis, tuberculosis
- Epilepsy
- Migraine (basilar)
- Cerebrovascular disease
- Vertebrobasilar insufficiency
- General
- Hematologic: anemia, polycythemia, hyperviscosity syndrome
- Toxic: alcohol
- Chronic renal failure
- Metabolic
Work-up
- Glucose check
- Full neuro exam
- TM exam
- ?CT/MRI - if symptoms consistent with central cause
Management
Peripheral
Symptomatic control
- Antihistamines
- 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
Cause Reversal
- Epley maneuver (see BPPV)
Central
- R/O CVA
- MRI
- 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
- ↑ 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