A Scientific and Clinical Approach to Acute Vertigo

Question 1

What are symptoms of a balance disorder?

Answer 1

Vertigo – the illusion of movement (usually rotational movement or “true vertigo” so SCC movement)

Dizziness – or giddiness – the descriptor is usually quite vague

Unsteadiness – or off-balance

Question 2

What are different types of illusory self motion?

Answer 2

low current
feeling a gentle rocking of self

high current
a feeling of violent spinning of self and room

Question 3

What are the most common emergency room vertigo diagnoses?

Answer 3

Benign paroxymal positional vertigo (BPPV) – 35%
Vestibular Neuritis – 15%
Migrainous Vertigo – 15%
Stroke – 5%
Mixed (syncope, anxiety...) – 30%
Meniere’s < 1%

Question 4

How would you examine a patient with acute vertigo?

Answer 4

eyes:
gaze
VOR
hallpike
fundoscopy

ears:
otoscopy

legs:
gait and tandem

Question 5

How can you distinguish between postural hypertension and BPPV?

Answer 5

does the patient get dizzy when they turn over in bed (no postural challenge) - if so it’s BPPV

• the side they feel dizzy on is the side with BPPV

Question 6

What are red flags of BPPV?

Answer 6

headache and atypical nystagmus

Question 7

How does vestibular neuritis present?

Answer 7

• Subacute onset (minutes – hours)
• Continuous vertigo
• Obvious ‘vestibular’ nystagmus
• Positive head impulse test
• Normal gait

Question 8

What are treatments for vestibular neuritis?

Answer 8

Vestibular sedatives for 24-36 hours
Mobilise at day 3
Treat any BPPV or migraine

Question 9

What are red flags for acute vertigo?

Answer 9

Headache - 40% posterior circulation stroke

Gait ataxia - may be only non-vertiginous manifestation
of cerebellar stroke

Hyperacute onset - suggests vascular origin

Vertigo + hearing loss - AICA or urgent ENT problem

Prolonged symptoms (> 4 days) - Floor of 4th ventricle problem

Question 10

What is oscillopsia?

Answer 10

seeing the environment moving

• indicates a nystagmus

Question 11

What is vestibular-motion perception?

Answer 11

sensation of motion (of self/environment)