Tutorial #31: Dizziness

Question 1

Describe the sensation of “Vertigo”, and it’s most common trigger

Answer 1

“The room is spinning”
Triggered by head movement

Question 2

Describe the senation of “Near Syncope”, and it’s most common triggers (x5)

Answer 2

“Feeling like you’re about to faint”
Triggered by standing (orthostatic) or warm environment, prolonged standing, seeing blood, straining (reflex/vasovagal)

Question 3

Describe the sensation of Disequilibrium (x3)

Answer 3

“Position of your body parts is not precisely known”

“Sensation of falling”

“difficulty walking or standing”

Question 4

With the HINTS exam, what 3 physical exam results are consistent with a PERIPHERAL cause of vertigo?

Answer 4

1. Head impulse test -> the PRESENCE of refixation saccade
2. Nystagmus -> unidirectional, horizontal
3. Skew deviation -> absent

Therefore, if the patient does not have a refixation saccade OR has vertical / direction changing nystagmus OR has skew deviation, then it is a central cause of vertigo (You only need one of the three)

Question 5

What 3 kinds of nystagmus suggest a central cause of vertigo?

Answer 5

1. bidirectional nystagmus
2. Nystagmus that is not inhibited by visual fixation on an object
3. Nystagmus that lasts > 1 min OR fails to fatigue with repitition

Question 6

In assessing vertigo, what are the first 3 steps you should take

Answer 6

Step 1: determine if vertigo is CNS in origin

Step 2: determine timing of vertigo episodes

Step 3: determine if it is triggered by head movement, or made worse by head movement

1. CNS: new severe headache, neck pain. Brainstem dysfunction, cerebellar dysfunction, abnormal nystagmus, etc.
2. if < 1 min, most likely BPPV, if lasting minutes to hours, might be TIA, vestibular migraine, meniere disease, etc. If Symptoms last for days, consider vestibular neuritis, stroke, or other CNS causes.
3. Vertigo triggered by motion, most likely BPPV.

TIP: for vertigo that is persistent, you can use HINTS exam to determine if central or peripheral.

Question 7

What is the most common cause of peripheral vertigo?

Answer 7

Benign paroxysmal positional vertigo (BPPV)

Question 8

What is the confirmatory test for BPPV?

Answer 8

Dix-Hallpike test

Question 9

What is the classical presentation of BPPV?

Answer 9

sudden abrupt onset of severe dizziness that occurs when changing head position, and lasts for < 1 min.

NOTE: Just because someone turns their head and their vertigo is worse, it does not mean its BPPV. Almost all causes of vertigo, whether peripheral or central, will worsen with head movement. BPPV is different because it is short, episodic, and triggered by head movement. It is confirmed with bedisde testing, such as the Dix-Hallpike, or other provocative maneuvers

Question 10

What is the treatment for BPPV (both 1st and 2nd line tx)?

Answer 10

The Epley Maneuver or other respositioning techniques are first-line. Medications (i.e. Gravol or Serc) can be used as second line.

Question 11

What is the classic presentation of acute vestibular neuritis?

Answer 11

can be precipitated by viral infection

Should not have any other focal neuro deficits

persistent vertigo that worsens with head movement, that can cause nausea/vomiting, and gait instability.

A HINTS exam would be helpful here to differentiate from a central cause.

Question 12

What is the etiology of acute vestibular neuritis?

Answer 12

Inflammation of the vestibular-cochlear nerve

Question 13

What is the treatment of acute vestibular neuritis?

Answer 13

Self-resolves, symptom management.

Steroids have mixed findings, and should only be used in very severe cases.

include antihistamines, and antiemetics

Question 14

What are positive predictors of vertigo due to cerebrovascular disease (ie. Central cause of vertigo) (x5)

Answer 14

1. Severe gait impairment
2. cerebellar abnormalities on exam
3. Positive HINTS test
4. Facial droop
5. motor function abnormalities (spasticity/weakness/etc)

Consider also if the patient has cardiovascular risk factors (HTN, T2DM, Smoking history, DLD)

Question 15

Central vertigo caused by cerebrovascular disease is often due to inadequate perfusion to what area in the brain (anterior or posterior)?

Answer 15

Inadquate perfusion to the posterior sections of the brain (ie. cerebellum or brainstem)

Question 16

What is ill-defined dizziness?

Answer 16

Dizziness that does not fit into any other subtypes (ie. not vertigo, dysequilibrium, or fainting)

Usually a diagnosis of exclusion, the dizziness is often of long duration and poorly defined. Patient may complain of other associated symptoms particularly if they have panic attacks (20-38% of patients experience these two things together)

Question 17

List 6 causes of central vertigo

Answer 17

 Stroke/Cerebrovascular disease
 Multiple sclerosis
 Cerebellar hemorrhage
 Migraine
 Brainstem tumors
 Vertebral artery dissection

Question 18

List 3 causes of peripheral vertigo

Answer 18

BPPV
 Vestibular neuritis
 Meniere disease

Question 19

A patient describes spontaneous/sudden onset vertigo since yesterday that is persistent and worse with head movements.
1. What vertigo syndrome is UNLIKELY and why?
2. What are your next steps in this patient’s management?

Answer 19

1. BPPV is unlikely because this is persistent, no paroxysmal (i.e. not short duration)
2. Complete vital signs/mental status/physical exam to see if there is an obvious explanation (i.e. if they very hypotensive, or have an obvious neuro deficit, that needs to be explored first). If no problem, HINTS exam is useful to figure out peripheral vs central cause.

Question 20

A patient describes spontaneous/sudden onset vertigo since yesterday that is persistent and associated with headache unilateral dysmetria.
1. What vertigo syndrome is UNLIKELY and why?
2. What are your next steps in this patient’s management?

Answer 20

1. Peripheral vertigo syndromes (like BPPV, vestibular neuritis) are unlikely because there are obvious central features such as headache and other neuro deficits
2. Patient will need to undergo neuroimaging to assess for stroke/bleed/vertebral dissection

Question 21

A patient describes spontaneous/sudden onset vertigo since yesterday that lasts less than a minute and only occurs with turning thier head. They have a completely normal exam other than a positive Dix-Hallpike.
1. What vertigo syndrome is UNLIKELY and why?
2. What are your next steps in this patient’s management?

Answer 21

1. Central causes of vertigo are unlikely because the episodes of vertigo are BRIEF, PAROXYSMAL and POSITIONAL.
2. Perform an Epley maneuvre and consider antihistamines (i.e. Gravol or Serc) if indicated

Question 22

Is this a central or peripheral cause of vertigo?

Stroke/Cerebrovascular disease

Answer 22

Central

Question 23

Is this a central or peripheral cause of vertigo?

Multiple sclerosis

Answer 23

Central

Question 24

Is this a central or peripheral cause of vertigo?

Cerebellar hemorrhage

Answer 24

Central

Question 25

# Is this a central or peripheral cause of vertigo? Migraine

Answer 25

Central

Question 26

# Is this a central or peripheral cause of vertigo? Brainstem tumors

Answer 26

Central

Question 27

# Is this a central or peripheral cause of vertigo? Vertebral artery dissection

Answer 27

Central

Question 28

# Is this a central or peripheral cause of vertigo? BPPV

Answer 28

Peripheral

Question 29

# Is this a central or peripheral cause of vertigo? Vestibular neuritis

Answer 29

Peripheral

Question 30

# Is this a central or peripheral cause of vertigo? Meniere disease

Answer 30

Peripheral

Question 31

# What is this the classic presentation of? Sudden abrupt onset of severe dizziness that occurs when changing head position, and lasts for < 1 min.

Answer 31

BPPV

Question 32

# What is this the classic presentation of? Persistent vertigo that worsens with head movement, that can cause nausea/vomiting, and gait instability. Still present even when head is at rest. No focal neurological deficits. Potentially precipitated by viral infection.

Answer 32

Acute Vestibular Neuritis (AVN) (Present while head is at rest is strong differentiator from BPPV)

Question 33

# These are findings that would support what cause of vertigo? 1. Severe gait impairment 2. Cerebellar abnormalities on exam 3. Positive HINTS test 4. Facial droop 5. Motor function abnormalities (spasticity/weakness/etc) 6. Vascular risk factors (DLD, DM, HTN)

Answer 33

CVA (posterior circ stroke)

Question 34

# What type of dizziness is this? "The room is spinning"

Answer 34

Vertigo ## Footnote Unrelated to the course but I was reading an interesting article talking about how asking about nature of dizziness isn't actually that helpful? Interesting to chew on but obviously it's just one study (https://pubmed.ncbi.nlm.nih.gov/17976352/).

Question 35

# What type of dizziness is this? "Feeling like you're about to faint"

Answer 35

Near-syncope

Question 36

# What type of dizziness is this? "Position of your body parts is not precisely known" "Sensation of falling" "difficulty walking or standing"

Answer 36

Dysequilibrium

Question 37

# Is this central or peripheral vertigo? Skew deviation on HINTS exam.

Answer 37

Central ## Footnote **Therefore, if the patient does not have a refixation saccade OR has vertical / direction changing nystagmus OR has skew deviation, then it is a central cause of vertigo (You only need one of the three)**

Question 38

# Is this central or peripheral vertigo? Vertical nystagmus on HINTS exam.

Answer 38

Central ## Footnote **Therefore, if the patient does not have a refixation saccade OR has vertical / direction changing nystagmus OR has skew deviation, then it is a central cause of vertigo (You only need one of the three)**

Question 39

# Is this central or peripheral vertigo? Absent refixation saccade on HINTS exam.

Answer 39

Central ## Footnote **Therefore, if the patient does not have a refixation saccade OR has vertical / direction changing nystagmus OR has skew deviation, then it is a central cause of vertigo (You only need one of the three)**

Question 40

# According to the algo in the reading, what is the next step? Patient has dizziness that is consistent with vertigo and has neurological findings on physical exam.

Answer 40

MRI (to eval for stroke/CNS pathology) | Literally from algo in reading

Question 41

# According to the algo in the reading, what is next step? Patient has dizziness that is consistent with vertigo. No neurological findings on exam. Patient states dizziness is spontaneous, with multiple episodes, and lasts minutes to hours. Also has intermittent hearing loss and tinnitus.

Answer 41

Probable Meniere disease

Question 42

# According to the algo in the reading, what is next step? Patient has dizziness that is consistent with vertigo. No neurological findings on exam. Patient states dizziness is spontaneous, with multiple episodes, and lasts minutes to hours. Associated with migraines.

Answer 42

Probable Vestibular Migraines

Question 43

# According to the algo in the reading, what is the next step? Patient has dizziness that is consistent with vertigo. No neurological findings on exam. Patient states dizziness is spontaneous, with multiple episodes, and lasts minutes to hours. Old age and has CV risk factors.

Answer 43

MRA (to eval posterior fossa TIA)

Question 44

# According to algo from reading, dx? Patient has dizziness that is consistent with vertigo. No neurological findings on exam. Patient states dizziness is spontaneous, monophasic, and has lasted days. Neuro + HINTS exam is -ve.

Answer 44

Vestibular Neuritis

Question 45

# According to algo in reading, next step? Patient has dizziness that is consistent with vertigo. No neurological findings on exam. Patient states dizziness is spontaneous, monophasic, and has lasted days. On exam, patient has headache, neck pain, and hasn't improved in the last 72hrs.

Answer 45

MRI (for CNS path) | Other indications for MRI include HINTS +ve, inability to walk, CNS ssx