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Evaluation of Dizzy Patients

Elizabeth A. Mauricio, MD

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Disclosure

Relevant Financial Relationships

None

Off-Label/Investigational Uses

None

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DIZZY

Dizzy

Dizzy

Dizzy

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Case 1: The spinner

67 year old man woke up this morning with a

sensation as though the room is spinning

which has persisted all day.

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Which finding suggests that his vertigo is most likely due to a posterior circulation stroke?

A. Left ear pain and hearing loss

B. Up-beating and torsional nystagmus evoked by Dix-Hallpike maneuver

C. Headache, nausea and vomiting

D. Horner syndrome

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Lateral medullary infarct (Wallenberg syndrome)

Case courtesy of Dr G Balachandran, Radiopaedia.org, rID: 12162

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Peripheral vs. Central Vertigo: HINTS Exam

•Head Impulse test

•Nystagmus

•Test of vertical Skew

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Head Impulse Test

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Nystagmus

•Peripheral vestibulopathy •Unidirectional nystagmus •Quick phases beat away from side of lesion

•Central lesion •Direction changing gaze evoked nystagmus •Dominantly vertical or torsional spontaneous nystagmus

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Test of Skew

•Peripheral vestibulopathy: no vertical movement

•Central lesion: vertical saccade upon uncovering

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HINTS Exam Findings in Acute Stroke

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Acute onset of Dizziness- When to Worry?

•Age >60

•Vascular risk factors

•Normal Head Impulse Test

•Focal Neurologic Signs

•Inability to walk

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Case 2: Another spinner

58 year old woman with 2 week history of room-

spinning sensation when she rolls over in bed,

lasting seconds in duration.

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Which is untrue about Benign Paroxysmal Positional Vertigo?

A. Characterized by episodic vertigo lasting 10-30 seconds provoked by certain tilting positions of the head, rolling over while supine, or straightening up after bending over

B. Dix-Hallpike maneuver is a simple bedside exam technique that induces the vertigo and nystagmus of the posterior canal type of BPPV

C. The Epley maneuver, when properly done, has a success rate of about 90%

D. BPPV is the least common disorder causing recurrent vertigo

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Which is untrue about Benign Paroxysmal Positional Vertigo?

A. Characterized by episodic vertigo lasting 10-30 seconds provoked by certain tilting positions of the head, rolling over while supine, or straightening up after bending over

B. Dix-Hallpike maneuver is a simple bedside exam technique that induces the vertigo and nystagmus of the posterior canal type of BPPV

C. The Epley maneuver, when properly done, has a success rate of about 90%

D. BPPV is the least common disorder causing recurrent vertigo

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Dix-Hallpike and Epley Maneuvers

Kevin A. Kerber, and Robert W. Baloh Neurol Clin Pract 2011;1:24-33

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Vertigo- Duration

•Seconds to minutes: BPPV

•Minutes to hours: TIA, migraine

•Hours to days: Meniere's, migraine

•Days to weeks: vestibular neuritis

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Case 3: The wobbler

•70 year old woman with a history of anxiety, migraine and fibromyalgia presents with a 10 month history of dizziness which began after a cruise

•Describes a constant sense of imbalance and nausea made worse by driving or riding in a car, reading, using the computer and playing Mahjong

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Case 3

•Neurologic examination was normal •No nystagmus •No ataxia •Romberg negative •Gait cautious, able to toe, heel and tandem

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Most likely etiology of dizziness?

A. Migraine

B. Benign Positional Paroxysmal Vertigo

C. Bilateral vestibulopathy

D. Vestibular paroxysmia

E. Chronic subjective dizziness

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Most likely etiology of dizziness?

A. Basilar migraine

B. Benign Positional Paroxysmal Vertigo

C. Bilateral vestibulopathy

D. Vestibular paroxysmia

E. Chronic subjective dizziness

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Historical Background

Karl Westphal 1871

Agoraphobia

Brandt and Dieterich 1980s-1990s

“Phobischer Attacken-Schwankschwindel”

(Phobic Postural Vertigo)

Drs. Jeffrey Staab, Michael Ruckenstein early 2000s

Chronic Subjective Dizziness

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CSD: Clinical Features

•Persistent sense of dizziness, unsteadiness which fluctuates in severity > 3 months

•Symptoms usually more severe when walking

•Exacerbated by: •Active or passive motion •Complex visual cues •Tasks requiring sustained focus

Staab J. Chronic subjective dizziness. Continuum Lifelong

Learning Neurol 2012;18(5):1118-1141.

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CSD: Clinical Features

•Precipitating factors •Previous acute or episodic vestibular disorders •Mild TBI or whiplash •Panic attacks, generalized anxiety •Dysautonomias •Dysrhythmias •Adverse drug reactions

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CSD: Clinical Features

•Exam is usually normal

•May have comorbid psychiatric disturbance (anxiety, depression)

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CSD

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CSD: Treatment

•No large-scale, controlled treatment trials

•Several studies support 3 prong approach: •Medication: SSRI, SNRI •Vestibular & balance rehab therapy •Cognitive behavioral therapy

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Causes of Dizziness • Benign paroxysmal positional vertigo

• Vestibular neuritis

• Meniere disease

• Vestibular Migraine

• Stroke, TIA

• Epileptic vertigo

• Multiple sclerosis

• Orthostatic hypotension

• Arrhythmia

• Wernicke syndrome

• Episodic ataxia syndrome

• Superior canal dehiscence syndrome

• Craniocervical junction syndromes

• Bilateral vestibular loss

• Mal de debarquement

• Chronic subjective dizziness

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Exam Pearls •Vitals

•?orthostatic

•Cardiovascular •?arrhythmia

•Oculomotor exam •Head impulse test •Nystagmus •Skew

•Ataxia

•Romberg

•Gait

•Dix-Hallpike

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Take home points

•Dizziness is a common complaint

•What does “dizzy” mean?

•History and examination are essential!

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mauricio.elizabeth@mayo.edu