DIZZINESS & VERTIGO

1. DIZZINESS & VERTIGO Trevor Langhan PGY-5 Resident rounds

2. 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

3. Case 1 • 75 year old lady • PMHx: DM, OA, Gout • Meds: metformin, glyburide, Vit B, multivit, Iron • Cc: Dizzy • HPI: stood up after lunch in mall • +++ lightheaded • Everything was fading to black • Mild nausea with sweating • Needed to sit or would have fainted • Layed down on bench in mall. • Now feels better

4. 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?

5. 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

6. 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

7. San Fran Syncope Rule • Inclusion: 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

8. Presyncopal Lightheadedness • Diagnoses not to miss • Cardiac Syncope • 1 yr mortality 18-33% • Neurologic Catastrophes • Ischemia or bleed • Hemorrhage • ruptured AAA, ruptured EP

9. Dizzy vs. Vertigo • Key to history is trying to differentiate • ‘what’s dizzy to you?’ • Fading to black vs. room spinning?

10. 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?

11. 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

12. 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

13. 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.

14. Peripheral vs. Central

15. ‘Toxic’ Labyrinthitis • Medication induced vestibular toxicity • Aminoglycosides • Anticonvulsants • Alcohol • NSAIDS • Gradually progressive Sx • Can get hearing loss & severe N & V • No positional nystagmus • Tx • Stop toxic drug • ?steroids

16. Peripheral • Benign Positional Peripheral Vertigo – BPPV • Due to canulith settling against cristae • +++ severe acute vertigo symptoms

17. Dix-Hallpike Test

18. Dix-Hallpike Test

19. 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

20. 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

21. Meniere’s Dz • No positional nystagmus on exam • Associated 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

22. 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

23. 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

24. 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)

25. 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

26. 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

27. Neuroanatomy

28. 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

29. 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

30. 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.

31. 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

32. 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

33. Peripheral vs. Central DDx