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Is it True Vertigo ?

• The Approach (Questions)
  • Is the dizziness true vertigo
  • If so, is it central or peripheral vertigo
  • Is the vertigo intermittent → likely benign
  • Constant vertigo is either acute peripheral vestibulopathy (APV) or a posterior circulation/cerebellar CVA

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• General Dizziness: 4 different etiologies
  • Lightheadedness/Presyncope
  • Vertigo
  • Dysequilibrium (neuromuscular disorder)
  • Psychiatric
• Definitions (Rosen’s Emerg Med, 6th ed. Ch 13. 2006)
  • True Vertigo: disorientation in space combined with a sense of motion
  • Hallucination of movement of self (subjective vertigo) or of environment (objective vertigo)

Central vs Peripheral Vertigo

General Approach

• Objective for vertigo is differentiating benign peripheral vertigo from life-threatening central vertigo, using the 5 criteria

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Symptoms

• Cerebellar CVA: acute onset and continuous
  • Other central vertigo is usually more gradual and continuous
• APV (acute peripheral vestibulopathy): gradual onset and continuous
• BPPV: Acute onset but intermittent

Nystagmus

• Central vertigo:
  • Vertical
  • Unilateral
  • Non-fatigable
  • Unsupressed: not suppressed with fixation of gaze (nystagmus persistent when looking straight at your finger)
  • Direction change: direction of nystagmus changes with eccentric gaze
• Vertical nystagmus ddx: central vertigo, PCP, EtOH (alcohol), drugs

Neurologic symptoms

• Neuro exam: 6Ds of an abnormal neuro exam:
  • Dizziness (vertigo)
  • Diplopia (double vision)
  • Dysphagia (difficulty swallowing)
  • Dysarthria (difficulty speaking)
  • Dysmetria (cerebellar ataxia)
  • Dysdiadochokinesia (impaired ability to perform rapid, alternating movements)
• Long-tract signs
  • Motor/sensory loss
• Ataxia
  • Central vertigo/cerebellar pts usually unable to walk

Auditory symptoms

• Auditory symptoms a sign of peripheral vertigo (acute labrynthitis)

6Ds

□ Dizziness
□ Diplopia
□ Dysphagia
□ Dysarthria
□ Dysmetria
□ Dysdiadochokinesia

HiNTS Test (Stroke 2009;40:3504-10)

• Head impulse test (Hi): (NEJM 2003;348:1027-32)
  • Bedside test of horizontal VOR (vestibuloocular reflex)
  • Start: Head turned to one side and eyes turned 10º from center to same side
  • Motion: Apply brief high acceleration head turn so that eyes end looking at examiner’s nose
  • Test: Catch up saccades on one side, but not the other indicates peripheral vestibular lesion on that side
• Nystagmus (N)
  • Nystagmus changes direction on eccentric gaze → central lesion
• Skew deviation (TS)
  • Eyes are vertically misaligned because of imbalance of vestibular tone → central lesion
  • Alternately cover each eye to test for realignment
• Positive test (central lesion-stroke)
  • Normal horizontal head impulse test, direction-changing nystagmus in eccentric gaze, or skew deviation (vertical ocular misalignment)
  • HINTS Test 100% sensitive, 96% specific for identifying stroke (Stroke 2009;40:3504-10)

Risk factor Assessment

• Isolated vertigo can be the only symptom in cerebellar stroke/TIA and posterior circulation hemorrhage
• Risk factors: Older age, male sex, and the presence of hypertension, coronary artery disease, diabetes mellitus, and atrial fibrillation

Peripheral vertigo

1. Vestibulopathy (APV)

Definition

• APV= Acute Peripheral Vestibulopathy or Acute Prolonged Vertigo
  • Prolonged vertigo definition: continuous vertigo lasting more than a few hours
  • Self limited, likely viral cause for symptoms → affecting peripheral vestibular portion of CN8 (Vestibulocochlear nerve)
• Clinical
  • Symptoms: gradual onset and continuous vertigo
  • Neuro: Normal neuro exam and non-concerning type of nystagmus
  • Head thrust test: positive, catch up saccades on one side

VESTIBULAR NEURITIS

• Clinical Presentation
  • Develops over hours and resolves over days, usually post-viral
  • May mimic infarct type symptoms
• Treatment
  • General (Antihistamines, anticholinergics, anti-emetics, benzodiazepines)
  • Directed treatment: Dexamethasone, valacyclovir

ACUTE LABYRINTHITIS

• Subtypes
  • Toxic: usually medication induced, has auditory symptoms and tinnitus
  • Serous: associated ENT infection, May have fever
  • Suppurative: severe symptoms, febrile, toxic → Admit, IV Antibiotics, ENT C/S

LABYRINTHINE INFARCT

• Abrupt onset, h/o vascular dz, associated with neuro signs (also considered central type vertigo)

PERILYMPHATIC FISTULA

• Associated with trauma, lifting, coughing, sneezing
• Fistula test: Vertigo and nystagmus induced by pressure in the external ear canal

2. BPPV

Etiology

• Free floating debris in posterior semicircular canal

Clinical

• Abrupt onset of vertigo seconds after change in head position, lasting less than a minute.

Diagnosis

• Dix-Hallpike
  • Use: for diagnosis, presence of paroxysmal positional nystagmus is most reliable finding in patients with BPPV (Am J Otol 1995;16:806-10)
  • Procedure:
    • Start: Seated with head turned 45º to side being tested
    • Motion: Quickly lower to supine position with head angled backward 45º off bed
    • Test positive: Nystagmus with affected side down, can continue to Epley from this position for treatment
    • Nystagmus is delayed in onset, fatiguable, and decreases with fixation

Treatment

• Canalith Repositioning Maneuvers
  • Epley and Semont (Ann Emerg Med 2001;37:392-8)
    • May not be better than standard medical therapy (J Emerg Med 2014;46(4):575)

3. Meniere’s disease

• Clinical
  • Attacks of vertigo preceded/accompanied by reduced hearing, tinnitus and pressure in ear
  • Attacks followed by residual hearing loss
• Treatment
  • Dietary restrictions (salt, caffeine, tobacco), Lasix, Betahistine, ENT referral
• Other causes of Peripheral Vertigo
  • Ear canal foreign body, trauma (labyrinth concussion), otitis media, cerumen impaction, medication (aminoglycosides)

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Central Vertigo

Cerebellar Stroke

Clinical Scenario

• Symptoms
  • Sudden onset/continuous vertigo
  • +/- Severe headache
• Nystagmus
  • Vertical, unilateral, nonfatigable, unsupressed
  • Skew deviation
• Neurologic symptoms
  • 5Ds (Dizziness, Dysphagia, Dysphonia, Dysmetria, Diplopia)
  • Long tract signs (motor/sensory)
  • Ataxia (unable to ambulate)
• Isolated vertigo
  • Definition: no other symptoms present except for vertigo
  • May simulate symptoms of vestibular neuritis (VN)
  • Cerebellar CVA vs VN (Neurology 2006;67:1178-83)
    • 10% isolated cerebellar infarct pts present with isolated vertigo symptoms (vestibular neuritis (VN) symptoms)
    • No patients with cerebellar infarct had a positive head thrust test

Caution

10% isolated cerebellar infarct patients present with isolated vertigo

Diagnosis

• CT
  • Can identify acute hemorrhage
  • Not sensitive for acute stroke (especially of posterior fossa)
  • Can identify large posterior CVA or mass effect (closed 4th ventricle)
• MRI
  • Modality of choice to rule out infarctions
  • Indication: (NEJM 1998;339:680-5)
    • Neurologic signs/symptoms
    • Sudden onset of vertigo in a patient with risk factors for stroke
    • Headache: new, severe headache accompanying the vertigo

MRI for Vertigo

□ Neurologic symptoms
□ Sudden onset of vertigo + stroke risk factors
□ Headache: new and severe