Vertigo

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	Rotatory-vertical, horizontal	Vertical
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

• HINTS Exam can reliably distinguish peripheral cause from cerebellar/brain stem CVA
  • 1. Head Impulse Testing
    • Tests vestibulo-ocular reflex
    • Have pt fix their eyes on your nose
    • Move their head in the horizontal plane to the left and right
      • If reflex is intact their eyes will stay fixed on your nose
      • If reflex is abnormal eyes will move w/ their head and won't stay fixed on your nose
    • It is reassuring if the reflex is abnormal!(due to dysfunction of the nerve)
  • 2. Nystagmus
    • Benign nystagmus only beats in one direction no matter which direction their eyes look
    • Bad nystagums beats in every direction their eyes look
      • If pt looks left, get left nystagmus, if looks right, get right-beating nystagmus
  • 3. Test of Skew
    • Vertical dysconjugate gaze is bad
    • Alternating cover test
      • Have pt look at your nose w/ their eyes and then cover one eye
      • 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)

DDX

1. Vestibular/otologic
   1. Benign Paroxysmal Positional Vertigo (BPPV)
   2. Traumatic: following head injury
   3. Infection: labyrinthitis, vestibular neuronitis, 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
   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
   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

Treatment

1. Epley maneuver (see BPPV)
2. Anticholinergics
   1. Scopolamine transdermal patch 0.5mg (behind ear) QID
3. Antihistamines
   1. Diphenhydramine (benadryl) 25-50mg IM, IV, or PO q4hr
   2. Dimenhydrinate (dramamine) 50-100mg IM, IV, or PO q4hr
   3. Meclizine (antivert) 25mg PO QID
4. Antidopaminergics
   1. Metoclopramide 10-20 IV or PO TID
5. Benzodiazepines
   1. Diazepam 2-5mg PO QID
   2. Clonazepam 0.5mg PO BID

Disposition

• Admit if unable to walk

Algorithm

Source

• Tintinalli