Vertigo

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
    • Distinct onset, but without a clear position/motion-induced trigger
    • Lasts min to hours
    • Typically asymptomatic on presentation
    • Benign: Anxiety, vasovagal syncope, Meniere's, vestibular Migraine
    • Dangerous: TIA, arrhythmia, PE
  • Acute Vestibular Syndrome (AVS)

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] 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

  1. Have patient fix their eyes on your nose
  2. 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

  1. 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

  1. Have patient 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
    • 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

Cause Reversal

  • Epley maneuver (see BPPV)

Central

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

  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
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