Vertigo: Difference between revisions

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[[File:Vertigo_and_Dizziness.jpg]]
[[File:Vertigo_and_Dizziness.jpg]]


===HINTS Exam===
===[[EBQ: HINTS Exam|HINTS Exam]]===
Can reliably^ distinguish peripheral cause from cerebellar/brain stem CVA in the Emergency Department population <ref>http://ec.libsyn.com/p/a/d/d/add761f2a2847ea5/hints-exam.pdf?d13a76d516d9dec20c3d276ce028ed5089ab1ce3dae902ea1d01c0873ed8cc5fe910&c_id=2502227</ref><ref>http://www.ncbi.nlm.nih.gov/pubmed/18541870</ref><ref>http://hwcdn.libsyn.com/p/1/c/d/1cd6b38a89c178a1/diff-of-vertigo.pdf?c_id=2502226&expiration=1380995436&hwt=0a8bc67ea910e018a1543ebea192f668</ref>
Proposed as method of distinguishing peripheral cause from cerebellar/brain stem CVA in the Emergency Department population <ref>http://ec.libsyn.com/p/a/d/d/add761f2a2847ea5/hints-exam.pdf?d13a76d516d9dec20c3d276ce028ed5089ab1ce3dae902ea1d01c0873ed8cc5fe910&c_id=2502227</ref><ref>http://www.ncbi.nlm.nih.gov/pubmed/18541870</ref><ref>http://hwcdn.libsyn.com/p/1/c/d/1cd6b38a89c178a1/diff-of-vertigo.pdf?c_id=2502226&expiration=1380995436&hwt=0a8bc67ea910e018a1543ebea192f668</ref>
#Head Impulse Testing
 
##Tests vestibulo-ocular reflex
'''Head Impulse Testing'''
##Have pt fix their eyes on your nose
#Tests vestibulo-ocular reflex
##Move their head in the horizontal plane to the left and right
#Have patient fix their eyes on your nose
###If reflex is intact their eyes will stay fixed on your nose
#Move their head in the horizontal plane to the left and right
###If reflex is abnormal eyes will move w/ their head and won't stay fixed on your nose
##If reflex is intact their eyes will stay fixed on your nose
##It is reassuring if the reflex is abnormal!(due to dysfunction of the nerve)
##If reflex is abnormal eyes will move w/ their head and won't stay fixed on your nose
#Nystagmus
#It is reassuring if the reflex is ''abnormal'' (due to dysfunction of the nerve)
##Benign nystagmus only beats in one direction no matter which direction their eyes look
'''Nystagmus'''
##Bad nystagmus beats in every direction their eyes look
#Benign nystagmus only beats in one direction no matter which direction their eyes look
###If pt looks left, get left nystagmus, if looks right, get right-beating nystagmus
#Bad nystagmus beats in every direction their eyes look
#Test of Skew
##If patient looks left, they should have left-beating nystagmus, if looks right, should see right-beating nystagmus
##Vertical dysconjugate gaze is bad
'''Test of Skew'''
##Alternating cover test
#Vertical dysconjugate gaze is bad
###Have pt look at your nose w/ their eyes and then cover one eye
#Alternating cover test
###When rapidly uncover the eye look to see if the eye quickly moves to re-align
##Have pt look at your nose w/ their eyes and then cover one eye
##If any of the above 3 tests are consistent w/ CVA obtain full work-up (including MRI)
##When rapidly uncover the eye look to see if the eye quickly moves to re-align
#If any of the above 3 tests are consistent w/ CVA obtain full work-up (including MRI)
 
{{HINTS Exam Primary Outcome}}
 
 


^Sensitivity (for posterior ischemic CVA):
*HINTS = 100%?
*MRI <48hrs after symptom onset = 83%
*MRI >48hrs = 100%?
*CT = 16%


^Positive test = INFARCT for posterior stroke
^Positive test = INFARCT for posterior stroke

Revision as of 15:51, 3 November 2014

Background

  • Perception of movement (rotational or otherwise) where no movement exists
  • Pathophysiology
    • Mismatch or asymmetric activity of visual, vestibular, and/or proprioceptive systems
  • Must distinguish peripheral from central cause
    • Peripheral: 8th CN, vestibular apparatus
    • Central: Brainstem, cerebellum

Clinical Features

Peripheral Central
Onset Sudden Sudden or slow
Severity Intense spinning Ill defined, less intense
Pattern Paroxysmal, intermittent Constant
Aggravated by position/movement Yes Variable
Nausea/diaphoresis Frequent Variable
Nystagmus Horizontal Vertical or multidirectional
Fatigue of symptoms/signs Yes No
Hearing loss/tinnitus May occur Does not occur
Abnormal tympanic membrane May occur Does not occur
CNS symptoms/signs Absent Usually present

Diagnosis

Algorithm

Vertigo and Dizziness.jpg

HINTS Exam

Proposed as method of distinguishing peripheral cause from cerebellar/brain stem CVA in the Emergency Department population [1][2][3]

Head Impulse Testing

  1. Tests vestibulo-ocular reflex
  2. Have patient fix their eyes on your nose
  3. Move their head in the horizontal plane to the left and right
    1. If reflex is intact their eyes will stay fixed on your nose
    2. If reflex is abnormal eyes will move w/ their head and won't stay fixed on your nose
  4. It is reassuring if the reflex is abnormal (due to dysfunction of the nerve)

Nystagmus

  1. Benign nystagmus only beats in one direction no matter which direction their eyes look
  2. Bad nystagmus beats in every direction their eyes look
    1. If patient looks left, they should have left-beating nystagmus, if looks right, should see right-beating nystagmus

Test of Skew

  1. Vertical dysconjugate gaze is bad
  2. Alternating cover test
    1. Have pt look at your nose w/ their eyes and then cover one eye
    2. When rapidly uncover the eye look to see if the eye quickly moves to re-align
  3. If any of the above 3 tests are consistent w/ CVA obtain full work-up (including MRI)
  • A positive HINTS exam: 100% sensitive and 96% specific for the presence of a central lesion.
  • The HINTS exam was more sensitive than general neurological signs: 100% versus 51%.
  • The sensitivity of early MRI with DWI for lateral medullary or pontine stroke was lower than that of the HINTS examination (72% versus 100%, P=0.004) with comparable specificity (100% versus 96%, P=1.0).



^Positive test = INFARCT for posterior stroke

  • Impulse Normal (abnormal indicates peripheral)
  • Fast-phase Alternates (saccades alternate direction)
  • Refixation on Cover Test

DDX

  1. Vestibular/otologic
    1. Benign Paroxysmal Positional Vertigo (BPPV)
    2. Traumatic (following head injury)
    3. Infection
      1. Labyrinthitis
      2. Vestibular Neuritis (Neuronitis)
      3. Ramsay Hunt syndrome
  2. Syndrome
    1. Meniere Disease
    2. Neoplastic
    3. Vascular
    4. Otosclerosis
    5. Paget disease
    6. Toxic or drug-induced: aminoglycosides
  3. Neurologic
    1. Vertebrobasilar insufficiency
      1. Head turning causes vertigo, diplopia, dysarthria, b/l loss of vision, syncope
    2. Lateral Wallenberg syndrome
    3. Anterior inferior cerebellar artery syndrome
    4. Neoplastic: cerebellopontine angle tumors
    5. Cerebellar disorders: hemorrhage, degeneration
    6. Basal ganglion diseases
    7. Multiple sclerosis
    8. Infections: neurosyphilis, tuberculosis
    9. Epilepsy
    10. Migraine (basilar)
    11. Cerebrovascular disease
  4. General
    1. Hematologic: anemia, polycythemia, hyperviscosity syndrome
    2. Toxic: alcohol
    3. Chronic renal failure
    4. Metabolic
      1. Thyroid Disease
      2. Hypoglycemia

Work-up

  1. Glucose check
  2. Full neuro exam
  3. TM exam
  4. ?CT/MRI - if symptoms consistent with central cause

Management

Peripheral

Symptomatic control

  1. Antihistamines
    1. Meclizine (antivert) 25mg PO QID
    2. Diphenhydramine (benadryl) 25-50mg IM, IV, or PO q4hr
  2. Anticholinergics
    1. Scopolamine transdermal patch 0.5mg (behind ear) QID
  3. Antidopaminergics
    1. Metoclopramide 10-20 IV or PO TID

Cause Reversal

  1. Epley maneuver (see BPPV)

Central

  1. R/O CVA
  2. MRI
  3. R/O Vascular insufficiency

Disposition

  • Most pts w/ peripheral vertigo can be discharged home
  • Most pts w/ central vertigo require urgent imaging and consultation while in the ED

See Also

Source

  • Tintinalli
  1. ↑ http://ec.libsyn.com/p/a/d/d/add761f2a2847ea5/hints-exam.pdf?d13a76d516d9dec20c3d276ce028ed5089ab1ce3dae902ea1d01c0873ed8cc5fe910&c_id=2502227
  2. ↑ http://www.ncbi.nlm.nih.gov/pubmed/18541870
  3. ↑ http://hwcdn.libsyn.com/p/1/c/d/1cd6b38a89c178a1/diff-of-vertigo.pdf?c_id=2502226&expiration=1380995436&hwt=0a8bc67ea910e018a1543ebea192f668
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