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
   1. Tests vestibulo-ocular reflex
   2. Have pt 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)
2. Nystagmus
   1. Benign nystagmus only beats in one direction no matter which direction their eyes look
   2. Bad nystagums beats in every direction their eyes look
      1. If pt looks left, get left nystagmus, if looks right, get right-beating nystagmus
3. 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)

^Sensitivity (Posterior Ischemic CVA): CT = 16% MRI <48hrs after symptom onset = 83% MRI >48hrs = 100%? HINTS = 100%?

DDX

1. Vestibular/otologic
   1. Benign Paroxysmal Positional Vertigo (BPPV)
   2. Traumatic (following head injury)
   3. Infection
      1. Labyrinthitis
      2. Vestibular Veuritis (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

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

• Most pts w/ peripheral vertigo can be discharged home

1. Most pts w/ central vertigo require urgent imaging and consultation while in the ED

Algorithm

Source

• Tintinalli