DIZZINESS

Question 1

MANAGEMENT

Answer 1

INITIAL MANAGEMENT: ACUTE VESTIBULAR SYNDROME

1. SCREEN FOR NEUROLOGICAL DEFECTS
   HINTS
   Focused Neurological Exam
   Gait exam
2. ANSWER THE FOLLOWING
   Is there central pattern nystagmus?

Is skew deviation present?

Is the head impulse test negative?

Are there any CNS signs on focused neurological exam?

Is the patient unable to walk unassisted?

If yes to any, treat as stroke

If no to all, treat as vestibular neuritis: give steroids, anti histamine for 3 days, early follow up with PCP

Question 2

DOCUMENTATION

Answer 2

HPI:

T - Timing
T - Triggers
A - Associated Symtoms
ES - Exam Signs
T - Testing

1. TIMING
   Acute and Continuous
   Episodic that is not triggered
   Episodic that is triggered
2. TRIGGERS
   Turing/movement
   Standing
3. ASSOCIATED SYMPTOMS
   Neurological Deficits
   Vision change
   Ataxia

Nausea
Vomiting
Nystagmus
Head Motion Intolerance and unsteadiness

Aura or headaches—-Migraine

Blister—–Ramsay Hunt

Neck pain—–Vertebral artery dissection

Chest pain——Aortic dissection

Deafness / Tinnitis ——Meniere’s

ASK ABOUT RED FLAGS

Dysarthria, Diplopia, Dysphagia, FND,
Anesthesia

Headache, Trauma, whiplash, neck pain

Gait disturbance

Palpitations

Chest Pain

4. EXAM SIGNS
   Orthostatic BP

Posterior Circulation Exam:
Cerebellar Signs
Brainstem (Cranial Nerves)
Visual Fields

Gait exam : truncal (sitting up in the stretcher), walking

For Acute Vestibular Syndrome:
HINTS - Acute Vestibular Syndrome

For Episodic Vestibular Syndrome:
Dix hallpike (posterior canal)
Supine Roll Test (horizontal canal)

5. TESTING
   CT Head (poor test for posterior stroke)

Diffusion Weighted MRI (best test, can be falsely negative within 48 hrs of an ischemic stroke)

CTA Arch to Vertex if concered with vertebral artery dissection

ECG (arrythmia)

Question 3

DDx: VERTIGO

Answer 3

ACUTE VESTIBULAR SYNDROME: acute onset dizziness that is continuously present over days

accompanied by nausea, vomiting, nystagmus, head motion intolerance and gait unsteadiness

Common Serious Causes:
POSTERIOR ISCHEMIC STROKE
Trauma
Post-Exposure

Common Benign Causes:
VESTIBULAR NEURITIS
Labyrinthitis

SPONTANEOUS EPISODIC VESTIBULAR SYNDROME: episodes that last minutes to hours, NOT triggered by head movement, usually lasting for minutes to hours

Common Serious Causes:
TIA

Common Benign Causes:
VESTIBULAR MIGRAINE (MCC)
MENIERE’S

TRIGGERED EPISODIC VESTIBULAR SYNDROME: episodes last seconds to minutes triggered by head movement or body movement, usually lasting for <1 minute

Common Benign Causes:
BPPV

Common Serious Causes:
CPPV
Orthostatic Hypotension due to serious medical illness

Question 4

HINTS EXAM

Answer 4

INDICATIONS
Constant hours or days of vertigo with nystagmus at rest or with sideways gaze

NYSTAGMUS
Unidirectionsl is Peripheral Bidirectional is central

TEST OF SKEW
ANY vertical skew is central

HEAD IMPULSE
Catch up saccade is peripheral Normal is normal or central

BEDSIDE HEARING
AICA stroke will have unilateral hearing loss

CENTRAL
ANY:
Central pattern of nystagmus
Skew deviation
Normal head impulse (no catch up)
Hearing loss
CNS signs on focused neuro exam
Patient unable to sit up or walk unassisted

PERIPHERAL
ALL:
Unidirectional nystagmus
No vertical skew
Catch up on head impulse
Normal hearing

Question 5

DIX HALPIKE

Answer 5

INDICATIONS
Triggered Episodic Vestibular Syndrome
Tests for posterior canal

MANEUVER
Rotate head to 20
Quickly lay patient flat
Observe eye movement for torsional nystagmus

EXAM FINDINGS: BPPV
Upbeat-torsional
5-30 seconds (crescendo−decrescendo intensity pattern)
(top corner of the eye rotating towards the floor)

EXAM FINDINGS: CENTRAL
Variable direction (usually pure downbeat or horizontal; almost never upbeat or torsional)
Variable duration (often persists >90 seconds if the position is held; rarely varies significantly in intensity)

Question 6

SUPINE ROLL TEST

Answer 6

INDICATIONS
Triggered Episodic Vestibular Syndrome
Tests for horizontal canal

EXAM FINDINGS: BPPV
Pure horizontal‡
30-90 seconds (crescendo−decrescendo intensity pattern)

EXAM FINDINGS: CENTRAL
Variable direction (usually pure downbeat or horizontal; almost never upbeat or torsional)
Variable duration (often persists >90 seconds if the position is held; rarely varies significantly in intensity)