DIZZINESS & VERTIGO

Trevor Langhan PGY-5

Resident rounds

Dizziness - Background

Dizziness = sensation of abnormal orientation in space

Very common complaint in the ED

Common cause for repeat physician visits

Patients older than 60 years

20% have experienced dizziness severe enough to affect their daily activity

Case 175 year old ladyPMHx: DM, OA, GoutMeds: metformin, glyburide, Vit B, multivit, Iron

Cc: DizzyHPI: stood up after lunch in mall

+++ lightheadedEverything was fading to blackMild nausea with sweatingNeeded to sit or would have faintedLayed down on bench in mall. Now feels better

Case 1

HR 88 BP 110/70 RR 16 Sat 95% afeb

Hgb 73, platelet 410, WBC 7.5

Lytes, Creat, Gluc, troponin, U/A all normal

CXR normal

EKG normal sinus

Physical exam

Unremarkable

Neuro exam normal, gait normal

PLAN?

San Fran Syncope Rule

1-3 % of ED visits are for syncope or pre-syncope

50% of patients don’t have a diagnosis at d/c

SF rule criteria are:

Abnormal EKG

Hematocrit < 30%

History of CHF

Complaint of SOB

Systolic BP < 90 mmHg

San Fran Syncope Rule

Who will have a serious event within 7 days

Derivation and validation study

98% and 96% sensitive

External Validation study:

Prospectively enrolled syncope and near-syncope

477 patients (good f/u in 93%)

12% had significant event in 7 days

Rule 89% sensitive & 42% specific

San Fran Syncope RuleInclusion: syncope or near-syncope b/t 8am & 10pm

SF rule exclusion criteria are:

LOC related to seizure (witnessed)

LOC due to Head trauma

Ongoing confusion (including dementia)

Intoxication

Age < 18 years

Non-english or spanish speaking

DNR

Lack of follow-up contact info

Presyncopal Lightheadedness

Diagnoses not to miss

Cardiac Syncope

1 yr mortality 18-33%

Neurologic Catastrophes

Ischemia or bleed

Hemorrhage

ruptured AAA, ruptured EP

Dizzy vs. Vertigo

Key to history is trying to differentiate

‘what’s dizzy to you?’

Fading to black vs. room spinning?

Neuro Exam

Most of us can do a rudimentary exam

Finer details often lacking

Some questions to consider:

Rhomberg?

Nystagmus?

Dysmetria?

EOM exam?

Pupillary findings?

Vertigo

Vertigo – defined more clearly as a sensation of disorientation in space combined with a sensation of motion.

Usually 2o to pathological basis, but need to differentiate benign from sinister

Most NB is to differentiate peripheral and central vertigo

Vertigo

Vestibular apparatus

3 semi-circular canals with cristae

Provide info about body angles and movement

Travel by CN VIII

Enter brainstem near Pons

Travels down two paths

MLF – medial longitudinal fasciculus

Vestibulospinal tract

Peripheral vs. Central

Peripheral causes usually benign and not needing acute intervention.

Central causes may have urgently needed intervention (cerebellar hemorrhage).

Changing or rapidly progressive symptoms should raise concern of impending posterior circulation occlusion.

Peripheral vs. Central

Peripheral Central

Onset Sudden Gradual S

Position Worse No Effect P

Intensity Very Not severe I

Nystagmus One direction Hor, vert, rotary

N

Neuro Symps Usually none Usually yes N

Auditory +/- tinnitus None E

Duration Seconds to minutes

Weeks to months

D

‘Toxic’ Labyrinthitis

Medication induced vestibular toxicityAminoglycosidesAnticonvulsantsAlcoholNSAIDS

Gradually progressive SxCan get hearing loss & severe N & V No positional nystagmusTx

Stop toxic drug?steroids

Peripheral

Benign Positional Peripheral Vertigo – BPPV

Due to canulith settling against cristae

+++ severe acute vertigo symptoms

Dix-Hallpike Test

Dix-Hallpike Test

Particle Repositioning Maneuvers

Cochrane (2005) – ”some evidence that the Epley manoeuvre is a safe effective treatment for posterior canal BPPV”

Studies vary from 66-100% success in alleviating or decreasing Sx

Effective in subjective vertigo

30-50% will have recurrence requiring repeat Tx

CASE

44 year old woman complains of ringing in her ears, needing to listen to the TV at higher volume, and the sensation that the room is spinning.

Her presentation is typical for:

Meniere’s Disease

Meniere’s Dz

No positional nystagmus on examAssociated tinnitus & fluctuating hearing loss (low frequency senorineural)Hearing loss may persist between episodes (need to consider acoustic neuroma in the Ddx)Tx

Low Na diet (<2 g/d)Antihistamines, diuretics, betahisitine (Serc) Chemical ablation of vestibular function (gentamicin)Surgery

Labyrinthitis & Neuronitis

Suspected viral etiology

Peak incidence in 30 to 50s

Acute severe vertigo increases rapidly in intensity (hrs) & subsides gradually (days)

Can have mild persistent positional vertigo for wks to mos

• Get N & V, but NO auditory Sx • Tx

– Prednisone for 10d may shorten course– Vestibular rehab

Acute Suppurative Labyrinthitis

• Coexisting acute exudative bacterial inner ear infection

• Vertigo, severe N & V & hearing loss• Febrile toxic pt• Tx

– Admit for IV Abx +/- surgical I & D

Central Vertigo

• May be gradual progressive symptoms over time or an acute worsening of a chronic complaint

• Cerebellar testing: – Cerebellar gait

• wide base, unsteady, irregular steps, unable to heel/toe walk

– Dysdiadochokinesia• rapid alternating movements

– Dysmetria• inability to arrest movement at desired point

(finger/nose testing)

Case

• 79 y lady c/o sudden dizziness and nausea• PMHx: a fib, hypertension, DM• Meds: Glyburide, altace, coumadin

• HR 80, BP 120/80, RR 12, Sat 97%• Unsteady gait, falling to left• Numbness to right face• Decreased sensation to left arm and leg• Right eyelid is drooped and pupil is small

Wallenberg’s Syndrome

• PICA occlusion • Hallmark is crossed findings

– Loss of pain & temp sensation on ipsilateral face

– Loss of pain & temp sensation to contralateral body

• Infarction of:– post inf cerebellum– dorsolateral medulla

• Vertigo, N & V, Nystagmus • Partial ipsilateral V, IX, X, XI CN deficits• Ipsilateral Horners syndrome

Neuroanatomy• lateral spinothalamic tract • contralateral deficits in pain

and temperature sensation from body

• spinal trigeminal nucleus • ipsilateral loss of pain and temperature sensation from face

• nucleus ambiguus • vagus and

glossopharyngeal nerves

• dysphagia, hoarseness, diminished gag reflex

• vestibular system • vertigo, diplopia, nystagmus, vomiting

• descending sympathetic fibers

• ipsilateral Horner's syndrome

Cerebellar Stroke

• Account for ~1.5% of all strokes• Sudden onset severe vertigo, H/A, N & V, ataxia• May have a “drop attack”• CT usually will not visualize posterior fossa well• If you want to r/o posterior fossa stroke you need a

MRI

• 25% of patients with RF for stroke who present to the ED with severe vertigo, nystagmus and postural instability will have a inferior cerebellar stroke

Cerebellar Stroke• What does one do in the elderly or those with

stroke RFs that appear to have peripheral vertigo?

• Tx– Antiplatelet Tx +/- warfarin, CVS RF

modification– Treatment of elevated ICP and emergent

surgical decompression may be life saving– Vestibular rehab once past acute phase

Cerebellar Hemorrhage• Similar presentation to cerebellar stroke• Often require surgical decompression and

hematoma evacuation• With appropriate surgical treatment, prognosis

is good• CN VI palsy (inability to abduct the eye) can

occur with cerebellar hemorrhage and ipsilateral nerve VI compression.

Vertebrobasilar Migraine

• Typically begins in adolescence• Multiple neuro Sx followed by headache:

– Vertigo – Dysarthria– Ataxia– Visual disturbances– Paresthesias

• Complete resolution of neuro abnormalities after attack subsides

Vertigo Ddx

• Vertigo Lasting for Seconds– BPV

• Vertigo Lasting for Minutes or Hours– Meniere’s Disease, Vertebrobasilar

Insufficiency (TIA), Migraine, Partial Sz, Perilymph fistula

• Vertigo Lasting for a Day or Longer– Vestibular Neuronitis/Labyrinthitis, Brainstem or

Cerebellar Stroke

Peripheral vs. Central DDxPeripheral Central

Acoustic neuroma A Cerbellary CVA C

Acute Otitis Media A Concussion C

BPV B Cervical Spine muscle C

Cerumen against TM C Epilepsy E

Meniere’s Disease D Multiple Sclerosis M

Vestibular Neuronitis E Migraine M

Foreign Body in canal F Tumor T

Labyrinthitis Trauma R

Neuronitis Abcess A

Trauma Vertebral basilar artery insufficiency

L

Subclavian Steal S