Assessment of Patients With Dizziness

Assessment of Patients Assessment of Patients with Dizziness (+/- Falls)with Dizziness (+/- Falls)

Dr Irene HubardDr Irene Hubard

Kettering General HospitalKettering General Hospital

Unexplained Dizziness / Loss of Unexplained Dizziness / Loss of Balance / Syncope or Pre-Balance / Syncope or Pre-SyncopeSyncope1.1. True VertigoTrue Vertigo

2.2. Generally off balance Generally off balance

3.3. Lightheaded / Pre-Syncopal / Lightheaded / Pre-Syncopal / SyncopalSyncopal

4.4. PsychosomaticPsychosomatic

5.5. (Falls for some other reason)(Falls for some other reason)






1.True Vertigo1.True Vertigo

•Vertigo is an illusion of rotatory of rotatory motion motion caused by asymmetry of neural activity between the left and right vestibular nuclei.

• Exacerbated by head movementExacerbated by head movement

•Vertigo is always temporary.

1.True Vertigo1.True Vertigo

• VESTIBULAR LESIONSVESTIBULAR LESIONS

• BPPVBPPV

• Vestibular neuronitisVestibular neuronitis

• Menieres DiseaseMenieres Disease

• Vestibular MigraineVestibular Migraine

• CEREBELLAR LESIONSCEREBELLAR LESIONS

• E.g. StrokeE.g. Stroke

Benign Paroxysmal Positional Benign Paroxysmal Positional Vertigo (BPPV)Vertigo (BPPV)

• Most common cause of vertigoMost common cause of vertigo

• Telephone diagnosis – historyTelephone diagnosis – history

• Repeated bouts over time – provoked Repeated bouts over time – provoked by rolling over in bed or looking up to by rolling over in bed or looking up to hang washing or downhang washing or down

• No abnormalities on examinationNo abnormalities on examination

• Positive Hallpikes testPositive Hallpikes test

Epley ManouvreEpley ManouvreLeft posterior semicircular canal BPPV.

Recurrent spontaneous Recurrent spontaneous vertigo: is it Menière’s disease vertigo: is it Menière’s disease or migraine?or migraine?• The patient with repeated attacks of The patient with repeated attacks of

spontaneous vertigo each lasting an hour or spontaneous vertigo each lasting an hour or more has either Menière’s disease or more has either Menière’s disease or migraine.migraine.

• Menieres Disease Menieres Disease – classically vertigo, – classically vertigo, vomiting, low freq hearing loss, ear fullnessvomiting, low freq hearing loss, ear fullness

• But hearing loss only mild and transient But hearing loss only mild and transient initially and may not be noticed initially and may not be noticed

• Vestibular migraineVestibular migraine – Vertigo and vomiting – Vertigo and vomiting may or may not be associated with headachemay or may not be associated with headache

The patient with a first attack The patient with a first attack of acute spontaneous vertigoof acute spontaneous vertigo• Acute vestibular neuritis• Cerebellar infarction

– 1. In the clinical context of a first ever attack of acute spontaneous vertigo, if the head impulse test is positive then the patient has acute vestibular neuritis

– 2. With a cerebellar infarct the nystagmus might be bilateral, might be vertical, and will not be well suppressed by visual fixation – that is, it will be obvious

– 3. A patient with a cerebellar infarct usually cannot stand without support even with the eyes open, whereas the patient with acute vestibular neuritis usually can

• Late complications of vestibular neuritis– BPPV, imbalance due to inadequate vestibular function

The head impulse testThe head impulse test






2. Generally off balance2. Generally off balance

• Bilateral vestibulopathy

• Hydrocephalus

• Posterior fossa lesions

• Progressive supranuclear palsy

• Cerebellar ataxia

• Orthostatic tremor

• Spinal cord disease

• Sensory neuropathy

Vestibular disordersVestibular disorders

• Unterbergers testUnterbergers test

• Cawthorn Cooksey ExercisesCawthorn Cooksey Exercises

Diagnoses that are likely to be Diagnoses that are likely to be wrong in a patient with isolated wrong in a patient with isolated

vertigovertigo• Vertibro-basilar ischaemia – usually other Vertibro-basilar ischaemia – usually other

brainstem signsbrainstem signs

• Otitis media – unless suppurativeOtitis media – unless suppurative

• Hearing symptoms, tinnitus and deafness, if Hearing symptoms, tinnitus and deafness, if unilateral and occurring at the same time as unilateral and occurring at the same time as the vertigo attacks, suggest an aural rather the vertigo attacks, suggest an aural rather than a brainstem problem. By contrast, than a brainstem problem. By contrast, sudden, temporary bilateral hearing loss sudden, temporary bilateral hearing loss does suggest brainstem ischaemia.does suggest brainstem ischaemia.


2.2. Generally off balanceGenerally off balance




Unexplained Syncope, Falls, Unexplained Syncope, Falls, DizzinessDizziness

True SyncopeTrue Syncope Dizziness DizzinessFallsFalls Pre-syncopal

Lightheadedness

True vertigo

History, examination, ECG indicates:

•Vasovagal syncope

•Orthostatic hypotension

•Drug-induced syncope

•Arrythmia

•Situational syncope

•Major psychopathology

History, examination, radiology suggests:

•BPPV

•Vestibular/cerebellar/ENT pathology

Hx & Exam:

•Parkinsons

•Cerebellar signs

•Periph neurop.

•CVA

•Other CNS signs

3. Lightheaded / Pre-Syncopal / 3. Lightheaded / Pre-Syncopal / SyncopalSyncopal

• Acute M.I. / ischaemiaAcute M.I. / ischaemia• Neurally mediated syndromesNeurally mediated syndromes

- Vasovagal syncope - Carotid sinus syndrome- Vasovagal syncope - Carotid sinus syndrome• Orthostatic hypotensionOrthostatic hypotension

- Autonomic failure- Drugs/ alcohol- Volume - Autonomic failure- Drugs/ alcohol- Volume depletion (e.g. Haemorrhage, diarrhoea, Addisons)depletion (e.g. Haemorrhage, diarrhoea, Addisons)

• Cardiac arrhythmiaCardiac arrhythmia-Bradycardia/ tachycardia-Bradycardia/ tachycardia

• Structural cardiac diseaseStructural cardiac disease-Aortic Stenosis-Aortic Stenosis

• Pulmonary EmbolismPulmonary Embolism

Syncope: EtiologySyncope: Etiology

OrthostaticCardiac

Arrhythmia

StructuralCardio-

Pulmonary

*

1• Vasovagal• Carotid

Sinus• Situational

CoughPost- micturition

2• Drug Induced• ANS

FailurePrimarySecondary

3• Brady

Sick sinusAV block

• TachyVTSVT

• Long QT Syndrome

4 • Aortic

Stenosis• HOCM• PulmonaryHypertension

5• Psychogenic• Metabolic

e.g. hyper-ventilation

• Neurological

Non-Cardio-

vascularNeurally-Mediated

Unknown Cause = 34%

24% 11% 14% 4% 12%

DG Benditt, UM Cardiac Arrhythmia Center

CARDIOVASCULAR CAUSES OF SYNCOPECARDIOVASCULAR CAUSES OF SYNCOPE • Neurally mediated syndromesNeurally mediated syndromes

Vasovagal syncope (VVS)Vasovagal syncope (VVS)Carotid sinus syndrome (CSS)Carotid sinus syndrome (CSS)Orthostatic hypotension (OH)Orthostatic hypotension (OH)Postprandial hypotensionPostprandial hypotensionSituational syncopes (cough, micturition, etc)Situational syncopes (cough, micturition, etc)

• Cardiac abnormalitiesCardiac abnormalitiesArrythmiasArrythmiasStructural (aortic stenosis, HOCM)Structural (aortic stenosis, HOCM)Low output states (pericardial effusion, CCF)Low output states (pericardial effusion, CCF)

• Hypovolaemic statesHypovolaemic statesHaemorrhage, GI loss (D & V), renal loss (diuretics, Haemorrhage, GI loss (D & V), renal loss (diuretics, Addison disease, diabetes mellitus/insipidus, etc)Addison disease, diabetes mellitus/insipidus, etc)

• MiscellaneousMiscellaneousPulmonary embolismPulmonary embolismTIATIA

NEURALLY MEDIATED NEURALLY MEDIATED SYNDROMES - SOME SYNDROMES - SOME

DEFINITIONSDEFINITIONS

• Vasovagal SyncopeVasovagal Syncope

• Carotid sinus syndromeCarotid sinus syndrome

• Orthostatic HypotensionOrthostatic Hypotension

Vasovagal Syncope Vasovagal Syncope (Neurocardiogenic syncope)(Neurocardiogenic syncope)

• Often a precipitating event or prolonged Often a precipitating event or prolonged head up tilt resulting in hypotension +/or head up tilt resulting in hypotension +/or bradycardia with reproduction of bradycardia with reproduction of presenting symptomspresenting symptoms

Carotid Sinus Carotid Sinus HypersensitivityHypersensitivity

• >3 seconds of asystole (cardioinhibitory) >3 seconds of asystole (cardioinhibitory) or a 50mmHg fall in systolic BP in the or a 50mmHg fall in systolic BP in the absence of cardioinhibition absence of cardioinhibition (vasodepressor) or both (mixed) during (vasodepressor) or both (mixed) during CSMCSM

Orthostatic HypotensionOrthostatic Hypotension

• 20mmHg fall in systolic or 10 mmHg fall in 20mmHg fall in systolic or 10 mmHg fall in diastolic BP within 3 minutes of standing diastolic BP within 3 minutes of standing or head up tilt.or head up tilt.

Aetiology of Orthostatic Aetiology of Orthostatic HypotensionHypotension

• CVS - Low cardiac output states (AS,HOCM),CVS - Low cardiac output states (AS,HOCM), HypovolaemiaHypovolaemia

• Neurogenic failure - Neurogenic failure - Primary – Shy-Drager, Parkinsons, MSAPrimary – Shy-Drager, Parkinsons, MSASecondary – Diabetes, alcohol, amyloidSecondary – Diabetes, alcohol, amyloid

• Endocrine – Addisons, PhaeochromocytomaEndocrine – Addisons, Phaeochromocytoma• Drugs – CVS, diuretics, antihypertensivesDrugs – CVS, diuretics, antihypertensives• Prolonged bed-restProlonged bed-rest• IdiopathicIdiopathic

Head-up Tilt Test (HUT)Head-up Tilt Test (HUT)

• Used to look for Used to look for neurally mediated neurally mediated reflex syncopal syndromes i.e:reflex syncopal syndromes i.e:– Vasovagal (neurocardiogenic) syncopeVasovagal (neurocardiogenic) syncope– Carotid Sinus SyndromeCarotid Sinus Syndrome

Head-up Tilt Test (HUT)Head-up Tilt Test (HUT)

• Unmasks VVS Unmasks VVS susceptibilitysusceptibility

• Reproduces Reproduces symptomssymptoms

• Patient learns VVS Patient learns VVS warning symptoms warning symptoms

• Physician is better Physician is better able to give able to give prognostic / prognostic / treatment advicetreatment advice

Head-up tilt table testing in the Head-up tilt table testing in the diagnosis of vasovagal syncope, carotid diagnosis of vasovagal syncope, carotid

sinus hypersensitivity, and related sinus hypersensitivity, and related disorders.disorders.

• Vasovagal syncope – Vasovagal syncope – Often precipitated by event Often precipitated by event or prolonged head up tilt causing hypotension +/- or prolonged head up tilt causing hypotension +/- bradycardia bradycardia with reproduction of presenting with reproduction of presenting symptomssymptoms..

• Carotid sinus hypersensitivity - Carotid sinus hypersensitivity - >3seconds of >3seconds of asystole (cardioinhibitory) or a 50mmHg fall in asystole (cardioinhibitory) or a 50mmHg fall in systolic BP in the absence of cardioinhibition systolic BP in the absence of cardioinhibition (vasodepressor) or both (mixed) during CSM.(vasodepressor) or both (mixed) during CSM.

• Orthostatic hypotension – Orthostatic hypotension – 20mmHg fall in systolic 20mmHg fall in systolic or 10mmHg fall in diastolic BP within 3 minutes of or 10mmHg fall in diastolic BP within 3 minutes of standing or HUT.standing or HUT.



3.3. Generally off balanceGenerally off balance



4. Psychosomatic4. Psychosomatic

• Anxiety Disorder / DepressionAnxiety Disorder / Depression

• HyperventilationHyperventilation

HyperventilationHyperventilation

• Nijmegen ScoreNijmegen Score

• Arterial Blood GasesArterial Blood Gases

Hyperventilation QuestionnaireHyperventilation QuestionnaireNijmegen ScoreNijmegen Score

• 16 Questions on symptoms such as 16 Questions on symptoms such as SOB, tingling, dizziness, palpitations, SOB, tingling, dizziness, palpitations, anxiety, chest tightness etcanxiety, chest tightness etc

• Score 0 – 4 for never, rarely, Score 0 – 4 for never, rarely, sometimes, often or very often sometimes, often or very often happenshappens

• Score >23 is significant (max 64)Score >23 is significant (max 64)

What I actually do with dizzy What I actually do with dizzy patients in clinicpatients in clinic

• Full historyFull history– True Vertigo/Impaired Balance/LightheadedTrue Vertigo/Impaired Balance/Lightheaded

• Examination Examination • CVS exam with Lying/Standing BP and ECGCVS exam with Lying/Standing BP and ECG• 24hr BP / 24hr ECG / ECHO (aortic 24hr BP / 24hr ECG / ECHO (aortic

stenosis)stenosis)• CNS exam including cerebellar signs/foot CNS exam including cerebellar signs/foot

sensationsensation• GaitGait• Hallpike TestHallpike Test• Unterbergers TestUnterbergers Test• RombergsRombergs

Conclusions and Take Home Conclusions and Take Home MessageMessage

• Decide whether patient has Decide whether patient has – true rotational vertigo true rotational vertigo – is just generally off balace or is just generally off balace or – describing lightheadedness describing lightheadedness – (occasionally psychogenic component)(occasionally psychogenic component)

In a patient with repeated In a patient with repeated attacks of vertigoattacks of vertigo

•Do the positional test and if positive for BPPV go on to a particle repositioning manoeuvre

•Order an audiogram and a caloric test and if they are normal think of migraine rather than Menière’s disease in a patient with recurrent vertigo

•Forget about vertebro-basilar transient ischaemic attacks as a cause of isolated recurrent vertigo

In the patient having a first In the patient having a first ever attack of acute isolated ever attack of acute isolated

spontaneous vertigospontaneous vertigo• (1) Learn to do the head-impulse (1) Learn to do the head-impulse

test. If positive think of labyrinthitis. test. If positive think of labyrinthitis. (2) If negative always think of (2) If negative always think of cerebellar infarction. cerebellar infarction.

•Think of cerebellar infarction in patients with vascular risk factors or cerebellar signs

In the patient who is generally In the patient who is generally off balanceoff balance

•Think of bilateral vestibular loss due to gentamicin, normal pressure hydrocephalus, early cerebellar ataxia, early progressive supranuclear palsy, sensory peripheral neuropathy and orthostatic tremor in the patient who is off balance for no obvious reason. Beware the posterior fossa tumour.

In the patient who is off balance:

• 1 Think of gentamicin vestibulotoxicity.

• 2 Think of normal pressure hydrocephalus.

• 3 Beware of the posterior fossa tumour or malformation / early cerebellar ataxia.

• 4 Think of early progressive supranuclear palsy

• 4 Think of orthostatic tremor.

• 5 Consider spinal cord or peripheral nerve pathology.

In the lightheaded patient (+/- In the lightheaded patient (+/- collapse/falls) think of:collapse/falls) think of:

• Low blood pressure due to various Low blood pressure due to various reasonsreasons

• Postural hypotensionPostural hypotension

• Neurocardiogenic syncopeNeurocardiogenic syncope

• Carotid sinus syndromeCarotid sinus syndrome

• Aortic stenosisAortic stenosis

• ArrythmiasArrythmias

ReferencesReferences

•Diagnosis and management of vertigo - Clinical Medicine Vol 5 No 2 March/April 2005 GM Halmagyi

•Assessment and treatment of dizziness J. Neurol. Neurosurg. Psychiatry 2000;68;129-134G M Halmagyi and P D Cremer

Documents

Assessment of Patients With Dizziness