Download Vertigo

Inpatient Evaluation of
The “Dizzy” Patient
Jaclyn Laine DO, APBN
OhioHealth Neurological Physicians
Objectives:
• Identify key history leading to more accurate diagnosis
• Distinguish clinical features of central versus peripheral
etiology
• Determine the “red flag” symptoms for pathologic vertigo
Anatomy
• Peripheral Vestibular System
– Vestibular aparatus: semicircular canals, utricle saccule and
CN VIII- vestibular nerve
• Central Vestibular System
– Vestibular nuclei at the ponto-medullary junction, cerebellum,
midbrain
Consensus Definitions for
Vestibular Symptoms
• Vertigo
– The sensation of self -motion with no motion is occurring or
distorted self motion during normal head movements
• Dizziness
– The sensation of disturbed or impaired spatial orientation
without a false or distorted sense of motion
• Unsteadiness
•
Feeling of being unstable without a particular directional preference
• Oscilopsia
– The false sense that the visual surround is oscillating
Timing is the most important detail !
• Acuity
– Acute or chronic
• Provoking nature
– Spontaneous or positional
• Episodic or prolonged
– Seconds, minutes, hours, days
– Fluctuations or no symptoms between episodes
Key Points in Past Medical history
• History of migraine
– With aura or vertigo induced by movement in surrounding
• Atherosclerotic risk factors
• CAD, known orthostasis
• Head trauma
• Medications: lithium, TCA’s ototoxic antibiotics, alcohol, AED’s
• Features pointing towards central etiology:
– Exam with postural and gait instability
– Nystagmus can be any direction, however
• Sometimes reverses direction when patient looks in the
direction of slow component
• Features pointing towards peripheral etiology
– Aural fullness, Hearing loss, tinnitus
– Sensation of instability - not wanting to walk
• Exam with normal posture and gait
– Nystamgus torsional horizontal, not purely vertical, doesn’t
reverse direction
• Vertigo is not continuous for more than a few weeks.
• Even with permanent lesions the central nervous system adapts
to the defect so that vertigo subsides over several weeks.
• Constant dizziness lasting months is usually psychogenic, not
vestibular.
– Some patients who say they have constant dizziness for
months actually mean that they are susceptible to frequent
episodic dizziness.
Common Categories of
Vestibular Symptoms
1. Acute, Spontaneous and prolonged
– (Acute vestibular syndrome)
2. Episodic, positional
– (BPPV and central mimics)
3. Episodic spontaneous
– (Vestibular migraine, Meniere's, TIA )
4. Chronic unsteadiness -with/without oscilopsia
– (Oscilopisa at rest – nystagmus brain stem lesion)
– (Oscilopsia with head motion - bilateral vestibular failure)
New onset dizziness
Common causes and dangerous Mimis
BENIGN
Dangerous Mimics
Seconds to hours- episodic
– BPPV
TIA, Cardiac Arrythmia
– Orthostatic hypotention
MI, PE, GI bleed
– Reflex syncope
Aortic dissection, atrial myoxma
Days to weeks- continuous
– Viral labrynthitis
– Vestibular neuritis
– Medication toxicity
Anticonvulsants
Brainstem/ cerebellar stroke
Bacterial labrinthitis/mastoiditis
Herpes zoster oticus
Brainstem encephalitis
Wernicke Syndrome
Toxic – lithium, etoh withdrawal
CO exposure
Key points
• Vestibular dizziness is always exacerbated or provoked by head
movement
– At least in the acute phase
– No matter if peripheral or central in origin
• Clear reproducible triggers for non-exertional vestibular
symptoms generally indicate a benign cause
Case #1
• 25 year old woman presented with recent episodic dizziness and
headache. This occurred spontaneously one or twice a week
during the prior 6 weeks. Lasting 5-10 minutes. No associated
neurologic symptoms were present. The pain was located behind
the left year and present throughout the last six weeks without
variation of severity.
– Personal history of episodic migraine holocephalic, nausea,
throbbing, dizziness, family history of migraine, no history of
vascular risk factors
Case Considerations
• Sounds like Vestibular migraine
– Young, female, personal history of migraine with
“dizziness”
– However non-flucuating continuous head pain with
referral to ear?
– What questions are missing?
• History of trauma
• History or recent illness, fever, ear drainage
• History of aural fullness, tinnitus hearing changes
Further questioning
• Reveals head and neck trauma from carrying a mattress about 2
months ago
• Continuous headache and lack of fluctuating points to a fixed
structural pathology
Imaging
CTA head and neck with attention to temporal bones
looking for mastoiditis, vascular structural pathology
Imaging revealed a vertebral artery dissection
Quick Tips
• Protective P’s
• If old and recurrent
– Periodic, Prolonged
• Recurrent Stereotyped episodes over years
• If symptoms are acute/subacute
• Painless
– IF painful
Red flags:
sudden < 30 minutes, severe, sustained >72 hours
Points to Remember
• Deadly D’s
Indicating vascular brainstem symptoms
• Diplopia
• Dysarthria
• Dysphagia
• Dysmetria ( clumsiness)
• Dysethesias (specific facial numbness)
• Drop attacks
• Down is up distortions ( room inverted)
• NO dyspnea ( cardiopulmonary)
• NO deafness ( vascular inner ear)
Case 2#
• 71 year old man presented with several months of episodic
spinning, lightheadedness and imbalance
– Last episode occurred for 10 seconds when her got our of
been. He sat down and felt normal within in 20 seconds
– He has been awakened by a spinning sensation
– A more recent spell was described at lightheadness with
standing in line at the grocery store
– Neurological Exam and imaging normal, cardiac work up with
Echo and EKG normal
– Dix halpike showed nystagmus with left head position
– Vestibular rehab improved symptoms, however continued to
have symptoms walking
– His continued symptoms warranted investigation and with
orthostatic vital signs were not significant
– Tilt table revealed BP to 75 systolic with normal HR and BP
• Blood pressure meds adjusted
• Low dose fludrocortisone
• Behavioral strategites
– This illustrates that the original history described two types of
“dizziness”
Case 3#
• 26 year old male presents with 3 days of recurrent, severe dizzy
episodes with ear fullness and sensitivity to sound. some last for
30 seconds, some for 10 minutes. This is brought on by exertional
activities. He moved to a new apartment in the last week.
• Perilymph Fistula
•
•
•
•
Episodic dizziness without true vertigo
Associated with heightened hearing or loss of hearing
Provoked by coughing or vasovagal
Caused by head trauma, heavy lifting, SCUBA
– Diagnosis: ENT, valsaval with nystagmus, MRI not usually
helpful, temporal bone CT rules out other pathology,
– Treatment: ENT
• Strict bed rest
• Possible surgery
Case #4
51 year old woman who noted sensation of her
right ear ‘being blocked’ this AM.
• Now has ringing and decreased hearing The room then
began to spin wildly She became diaphoretic, nauseated
and vomited
• The spinning lasted about 60 minutes, then abated
• She now has a sensation of residual dysequilibrium
several hours later
Case #5
• 50 y/o woman suddenly feels overwhelming tilting sensation,
feels her legs become rigid and abruptly falls to the ground
Recovers to normal after a few seconds
•
Prior history at age 43 of single episode of tinnitus with dizziness
lasting several hours with complete resolution
Diagnosis in both cases
• Meniere’s
• Both are characteristic variants
Meniere’s
•
Two or more definitive spontaneous episodes of vertigo 20
minutes or longer
• Audiometrically documented hearing loss on at least one
occasion
• Tinnitus or aural fullness
• Other causes excluded
Probable Meniere's
• One definitive episode of vertigo
• Audiometrically documented hearing loss on at least one
• occasion
• Tinnitus or aural fullness
• Other causes excluded
Treatment
•
•
•
•
Diazide diuretic
Strict low Na intake
Vestibular suppressant
Stress Reduction
– In severe cases surgical management
Eye movement testing
•
A word on nystagmus. . .
– No one likes to interpret it
High Points:
– Nystagmus that fatigues- peripheral
– Persistent downbeat- central
– Pathologic Gaze evoked nystagmus
• Vertical ( central)
• Asymmetric
• Present within 30 degrees of primary gaze
Case 6
• 65 year old female with history of mild imbalance and more
episodes of vertigo when lying in bed at night.
• Examination shows:
• subtle downbeat nystagmus when gazine right and left
• Dix hallpike in both directions triggers downbeat nystagmus only
Where is the most likely localization?
A: cerebellum
B:lateral semicircular canal
C: vestibular nerve right
D: saccule
• Cerebellum
• Gazed evoke downbeat nystagmus
• Persistent positional downbeat nystagmus
• Despite central etiology- cerebellar lesions can cause prominent
positional symptoms
Conclusions
• Initial history for subjective sensation and associated symptoms is
key in establishing appropriate differential
• Always perform eye movement testing, coordination testing, and
gait testing
• Timing of symptoms is more important than subjective description