A Scientific and Clinical Approach to Acute Vertigo

Question 1

What is the most common cause of Vertigo?

Answer 1

BPPV

Question 2

oscillopsia

Answer 2

seeing environmental motion

Question 3

What is seeing environmental motion called and what does it indicate?

Answer 3

• it is called oscillopsia

- it indicates nystagmus

Question 4

Vestibular motion perception vs. seeing environmental motion

Answer 4

• vestibular motion perception = sensation of motion of self or the environment
• seeing environmental motion = oscillopsia

Question 5

In what way can you ask the patient to clarify the type of dizziness they are experiencing?

Answer 5

Self or environmental motion (eyes shut)

• Rocking like a boat
• Spinning like a merry go round
• Floating

=> describe the symptoms in words

Question 6

What is the vestibular system responsible for?

Answer 6

• detecting movement, acceleration

- stabilisation of gaze

Question 7

Illusory self motion at high and low current

Answer 7

Low current: Feeling of gentle rocking of self

High current:A feeling of violent spinning of self & room

Question 8

What are the most common A&E vertigo diagnoses?

Answer 8

• BPPV – 35%
• Vestibular Neuritis – 15%
• Migrainous Vertigo – 15%
• Stroke – 5%
• Mixed (syncope, anxiety…) – 30%
• Meniere’s < 1%

Question 9

What should you exclude first when examining patients with vertigo?

Answer 9

• postural hypotension
• PE
• cardiac dysrythmia

=>postural BP, arterial saturation, ECG

Question 10

What are the main vestibular diagnoses in ACUTE vertigo?

Answer 10

• BPPV
• Vestibular Neuritis
• Migrainous Vertigo
• Stroke (cerebellar)
• (Meniere’s – rare)

Question 11

What are core examinations in vertigo>

Answer 11

Eyes:

• cover
• gaze
• VOR
• Hallpike
• Fundoscopy

Ears:
- otoscopy

Legs:
- gait + tandem (walking one foot in front of the other)

Question 12

What would you look for in fundoscopy when examining a vertigo patient?

Answer 12

1. Retina – position of disc and macula
2. Spontaneous nystagmus?
3. Effect of visual fixation on nystagmus?

Question 13

What would you look for when examining the ears of a patient with vertigo?

Answer 13

• Hearing (if complaint)
• Otoscopy
-> Usually informative in acute vertigo
(except for looking for VZV vesicles in acute unilateral peripheral vestibular loss or suppurative infection in meningitis)

Question 14

What would you look for when examining the legs of a patient with vertigo?

Answer 14

• Gait
  
  • Narrow based?
• Tandem walking
  
  • Count how many mistakes out of 10 tandem steps.
• Romberg
  
  • See if eye closure affects balance.
  • Can they maintain balance for >20s without vision.

Question 15

BPPV

Answer 15

• most common cause of vertigo
• caused by dislocated cristal in semilunar canal
• occurs in change of position with nystagmus
• only lasts for a short time (sec-min) after position change and then goes away
• treatment of posterior canal BPPV: Epley, Semont manoeuvre

Red flags:

• headache
• atypical nystagmus

Question 16

Vestibular neuritis

Answer 16

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

Treatment:
• Vestibular sedatives for 24-36 hours • Mobilise at day 2 or 3
• Treat any BPPV or migraine

Red flags:
• 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 17

Acute vestibular migrane

Answer 17

• History of migraine
• Can have acute vertigo without prominent headache • Recurrent
• Diagnosis of exclusion -

Main DD is cerebellar stroke

Red flags: 
• Headache
• Gait problems
• Hyperacute onset
• Hearing loss
• Prolonged symptoms (>4 days)

Question 18

Cerebellar stroke and Vertigo

Answer 18

• Thunderclap onset vertigo (Embolic - Valsalva? Atrial fibrillation?)
• Dissection – neck pain (stretching, trauma?)
• Poor balance - unable to walk or even sit
• Headache

Red flags:
• Headache
• Gaitproblems
• Hyperacute onset
• Hearing loss
• Prolonged symptoms (>4days)