VERTIGO AND DIZZINESS

Objectives

• Definition
• Characteristics of central and peripheral vertigo
• List causes central and peripheral vertigo
• History and physical examination.
• Perform HINT EXAM.
• Acute management and disposition.

Dizziness

• Very common yet complex neurologic symptom, reflecting a disturbance in:

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• Balance perception and spatial orientation

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• It is often used as a catch all word for many things:
• Weakness, light-headedness, unsteadiness, depression.

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4 historical categories

• Vertigo : Vertigo is an illusion of motion, typically described as the room spinning.

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• near syncope : feeling faint or lightheaded.

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• Disequilibrium: is a sense of unsteadiness when walking, disruption between the sensory inputs and motor outputs.
• nonspecific dizziness: related to a polysensory disorder with an anxiety component.

Pathophysiology

• Visual impulses (eyes)
• Body position in space

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• Proprioceptive (muscles, joints, small nerves in the body)
• Relative positions of parts of the body
• Neck position particularly important in relation to visual and otic input

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• Vestibular systems (otic labyrinths)
• Maintain head position and stabilize head movement

All these systems send information to the brain Connected through the cerebellum by the vestibular nuclei in the brainstem

Vestibular systems

• Maintains head position and movement

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• Within the inner ear in the temporal bone

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• Vulnerable to:
• Trauma, infection, blood-borne toxins

Nystagmus

• Unilateral horizontal-rotatory nystagmus arises from vestibular disease

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• Vertical nystagmus is usually a central cause – in the brainstem or cerebellum

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Types

• Upbeat nystagmus (CENTRAL , COULD BE PREPHERAL)
• Periodic alternating nystagmus (CENTRAL)
• See-saw nystagmus (CENTRAL , COULD BE PERIPHERAL)
• Downbeat nystagmus : Lesions of the vestibulocerebellum and underlying medulla (CENTRAL)
• Pendular nystagmus (CENTRAL)
• Spasmus Nutans
• Torsional - Lateral medullary syndrome (Wallenberg syndrome)
• Abducting nystagmus of internuclear ophthalmoplegia (CENTRAL)
• Gaze evoked (CENTRAL)

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Acute vestibular syndrome

• A clinical condition in which dizziness develops acutely, is constant, persists longer than a day.
• Accompanied by nausea or vomiting, unsteady gait, nystagmus, and intolerance to head motion.

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Compare characteristics of peripheral and central vertigo�

Risk factors for central cause or vertigo

• TIA and stroke risk factors, including:

older age - male - HTN - CAD - DM - A fib - smoking

• Interesting facts :
• Isolated vertigo can be the only initial sign of cerebellar and posterior circulation strokes / TIAs / infarctions

Medication can cause vertigo

• Aminoglycosides
• Anticonvulsants
• Alcohols
• Quinine
• Quinidine
• Minocycline

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History

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1. Past medical history used to determine if true vertigo exists.
2. The time of onset and the duration of vertigo.
3. True instability, disequilibrium, or ataxia indicates a higher likelihood of a central process (present before & after treatment)
4. LOC
5. Auditory symptoms peripheral cause : middle and inner ear diseases
6. Associated neurologic symptoms : STROKE
7. Head injuries / Neck injuries
8. Travel / Diving / altitude
9. MEDICATIONS
10. Associated sx nausea vomiting

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physical examination

• Vital signs :
• pulse and blood pressure should be checked on both sides , orthostatic hypotension
• Signs of trauma (head/neck)
• Head and Neck : Carotid or vertebral artery bruits suggest atherosclerosis and risk for TIA or stroke ,the vertebral artery can be auscultated in the supraclavicular region.
• Ear examination : effusion , signs of infection.
• Eye examination (pupils/fundoscopy / extraocular movement) ,Nystagmus
• positional testing

Neurological examination �

Cerebellar function :

Rapid alternating movements

finger-to-nose pointing

Gait - ataxia

• (Consistent falling or a grossly abnormal gait) should suggest a central lesion, especially in a patient whose vertiginous symptoms have subsided).

Examination of the eyes

• Papilledema
• Third cranial nerve
• A sixth cranial nerve palsy ipsilateral to the hemorrhage may result from early brainstem compression by the expanding hematoma.
• nystagmus
• Central causes of nystagmus are purely vertical, downbeating (fast phase beating toward the nose), non-fatigable, direction changing with gaze, or spontaneous pure torsional.

HINTS EXAM

• A negative HINTS examination can rule out a stroke better than a negative MRI with DWI in the first 24 to 48 hours after symptom onset with a specificity of 96%

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• Excluded Hx of recurrent vertigo with or without auditory symptoms
• A positive HINTS exam: 100% sensitive and 96% specific for the presence of a central lesion if any one positive for cenctral

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• Reassuring Hints exam :
• Unidirectional nystagmus
• No vertical skew
• Abnormal head impulse
• Not Reassuring Hints exam :
• Bidirectional nystagmus
• Abnormal vertical skew
• Normal head impulse

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Acute management�

Disposition

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1-Documented or suspected VBI or cerebellar hemorrhage or infarction require diagnostic evaluation, treatment , admission.

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2-In patients older than age 55 with vascular risk factors, admission for observation and imaging of cerebral vasculature should be considered if the diagnosis is not certain.

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3-Severe Peripheral vertigo with intractable vomiting, inability to walk for admission.

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DISCHARHE :

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young patients with peripheral causes of vertigo can be discharged from the ED after symptoms have been controlled , follow up.

Take home message

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• -Nystagmus / Diagnostic maneuvers /proper history and neurological examination guiding you to diagnosis and who needs further investigations .

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• -Central cause and severe symptoms of Peripheral causes for admission

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• Mild peripheral vertigo discharge with follow up .

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• THANK YOU

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