Spinning on that Dizzy Edge Rebecca Jeanmonod, MD, FACEP St. Luke’s Hospital Department of Emergency Medicine Spinning on that Dizzy Edge Disclosure Rebecca Jeanmonod, MD, FACEP, has no relevant financial relationships to disclose. It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest. If conflicts are identified, they are resolved prior to confirmation of participation. Only participants who have no conflict of interest or who agree to an identified resolution process prior to their participation were involved in this CME activity. Learning Objectives • Identify the difference between vertigo, disequilibrium, intoxication, near- syncope, and psychiatric dizziness. • Identify helpful tests to distinguish peripheral from central vertigo. • Understand how to treat different kinds of vertigo. Which of the following is true about central vertigo? A. It is associated with hearing problems half the time. B. The associated nystagmus extinguishes with fixation. C. It is worse with movement. D. It is treated with high-dose meclizine. E. It is always associated with a stroke. Real-Life Approach to Dizziness Photo courtesy of Rebecca Jeanmonod, MD Patient complains of dizziness. What is your first question?
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Spinning on that Dizzy Edge
Rebecca Jeanmonod, MD, FACEP
St. Luke’s Hospital
Department of Emergency Medicine
Spinning on that Dizzy Edge
Disclosure
Rebecca Jeanmonod, MD, FACEP, has no relevant financial relationships to disclose.
It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest. If conflicts are identified, they are resolved prior to confirmation of participation. Only participants who have no conflict of interest or who agree to an identified resolution process prior to their participation were involved in this CME activity.
Learning Objectives
• Identify the difference between vertigo, disequilibrium, intoxication, near-syncope, and psychiatric dizziness.
• Identify helpful tests to distinguish peripheral from central vertigo.
• Understand how to treat different kinds of vertigo.
Which of the following is true about central vertigo?
A. It is associated with hearing problems half the time.
B. The associated nystagmus extinguishes with fixation.
C. It is worse with movement.
D. It is treated with high-dose meclizine.
E. It is always associated with a stroke.
Real-Life Approach to Dizziness
Photo courtesy of Rebecca Jeanmonod, MD
Patient complains of dizziness. What is your first question?
Spinning on that Dizzy Edge
WTH Do You Mean By “Dizzy?”
WTH Do You Mean By “Dizzy?”
Spinny
Off-balance Fainty
Crazy
Drunky
Public domain
Flickr.comPhotos courtesy of Rebecca Jeanmonod, MD
73 yo with a chief complaint of dizziness
• Feels dizzy with standing or walking
• Thinks she might fall
• Symptoms present for months
• H/o Parkinson’s
73 yo with a chief complaint of dizziness
• Feels dizzy with standing or walking
• Thinks she might fall
• Symptoms present for months
• H/o Parkinson’s
What is this?
• No nystagmus
• Orthostatic hypotension
• Cranial nerves intact
• Shuffling gait
Vertigo
Disequilibrium Near Syncope
Psychiatric
Symptoms when walking
Sensory impairment
Postural hypotension
Movement disorders
Abnormal gait
Absence of nystagmus
Intoxicated
WTH Do You Mean By “Dizzy?” 52 yo with a chief complaint of dizziness
• EMS called because patient fell
• Symptoms started 30 minutes ago
• Feels a little nauseated
Spinning on that Dizzy Edge
52 yo with a chief complaint of dizziness
• EMS called because patient fell
• Symptoms started 30 minutes ago
• Feels a little nauseated
• Rotatory and horizontal nystagmus
• Orthostatic hypotension
• Cranial nerves intact
• Blood shot eyes
• Slurred speech
• Broad-based gait
What is this?
WTH Do You Mean By “Dizzy?”
Vertigo
Disequilibrium Near Syncope
Psychiatric
Intoxicated
Presence of nystagmus
History of substance use
Postural hypotension
Other neuro findings
40 yo with a chief complaint of dizziness
• Patient was in a car accident
• Symptoms present regardless of position
• Has had persistent dizziness for months
40 yo with a chief complaint of dizziness
• Patient was in a car accident
• Symptoms present regardless of position
• Has had persistent dizziness for months
• No nystagmus
• Cranial nerves and gait normal
What is this?
WTH Do You Mean By “Dizzy?”
Vertigo
Disequilibrium Near Syncope
Psychiatric
Intoxicated
Absence of nystagmus
Psychiatric history
No other neuro findings
Non-physiologic course
70 yo with a chief complaint of dizziness
• Patient was moving bowels and felt dizzy
• Had blurry dark vision for a minute or two
• Now feels better
Spinning on that Dizzy Edge
70 yo with a chief complaint of dizziness
• Patient was moving bowels and felt dizzy
• Had blurry dark vision for a minute or two
• Now feels better
• No nystagmus
• Cranial nerves and gait normal
What is this?
WTH Do You Mean By “Dizzy?”
Vertigo
Disequilibrium Near Syncope
Psychiatric
IntoxicatedTransient symptoms
Seated or standing
Absence of nystagmus
No other neuro findings
60 yo with a chief complaint of dizziness
• Symptoms worsening over last hour
• Has some nausea
• Feels like she might fall
• Recent URI
60 yo with a chief complaint of dizziness
• Symptoms worsening over last hour
• Has some nausea
• Feels like she might fall
• Recent URI
• Horizontal nystagmus
• Can walk without assistance
What is this?
WTH Do You Mean By “Dizzy?”
Vertigo
Disequilibrium Near Syncope
Psychiatric
Intoxicated
Nystagmus
Symptoms worse with movement
Not positional
NystagmusRapid onset
Supine sxs
Disequilibrium
Near syncope
Vertigo
Psychiatric
Intoxicated
Comorbids
+/-
+/-
- - -
++
+/-
+
+
+
+
-
-
-
+
+
++/-
+/-
Spinning on that Dizzy Edge
NystagmusRapid onset
Supine sxs
Disequilibrium
Near syncope
Vertigo
Psychiatric
Intoxicated
Comorbids
+/-
- - -
+
+/-
+
+
+
+
-
-
-
+
+
++/-
+/-
What About Vertigo?
Vertigo is not a diagnosis, it is a symptom from which you form a
differential
Differential Diagnosis: Vertigo
• Benign paroxysmal peripheral vertigo
• Vestibulitis
• Labyrinthitis
• Meniere’s disease
• Perilymph fistula
• Migrainous
• Stroke
• Multiple sclerosis
• Tumors
• Neurodegenerative disorders
• Drugs
• Benign paroxysmal peripheral vertigo
• Vestibulitis
• Labyrinthitis
• Meniere’s disease
• Perilymph fistula
• Migrainous
• Stroke
• Multiple sclerosis
• Tumors
• Neurodegenerative disorders
• Drugs
CentralPeripheral
• Benign paroxysmal peripheral vertigo
• Vestibulitis
• Labyrinthitis
• Meniere’s disease
• Perilymph fistula
• Migrainous
• Stroke
• Multiple sclerosis
• Tumors
• Neurodegenerative disorders
• Drugs
CentralPeripheral
Spinning on that Dizzy Edge
Peripheral
BPPV Vestibulitis
Labyrinthitis
Meniere’sPerilymph fistula
If it’s been there for 3 years, what kind of vertigo is it?
Clinical pearl: no vertigo lasts forever
What kind of vertigo is worse with movement?
Clinical pearl: all vertigo is worse with movement
How does nystagmus help you distinguish central from
peripheral?
Spinning on that Dizzy Edge
What You’ve Heard About Nystagmus
What You’ve Heard About Nystagmus
• Peripheral– Extinguishes
• Central– Does not extinguish
Peripheral Central
What You’ve Heard About Nystagmus
• Peripheral– Extinguishes
– Suppressed with fixation
• Central– Does not extinguish
– Not suppressed with fixation
Peripheral Central
What You’ve Heard About Nystagmus
• Peripheral– Extinguishes
– Suppressed with fixation
– Better with eyes closed
• Central– Does not extinguish
– Not suppressed with fixation
– No difference with eyes closed
Peripheral Central
What You’ve Heard About Nystagmus
• Peripheral– Extinguishes
– Suppressed with fixation
– Better with eyes closed
– Horizontal or rotatory nystagmus only
• Central– Does not extinguish
– Not suppressed with fixation
– No difference with eyes closed
– Vertical nystagmus
Peripheral Central
What You’ve Heard About Nystagmus
• Peripheral– Extinguishes
– Suppressed with fixation
– Better with eyes closed
– Horizontal or rotatory nystagmus only
– Severe or sudden symptoms
• Central– Does not extinguish
– Not suppressed with fixation
– No difference with eyes closed
– Vertical nystagmus
– Mild or insidious symptoms
Peripheral Central
Spinning on that Dizzy Edge
What’s True About Nystagmus
• Peripheral– Extinguishes
– Suppressed with fixation
• Central– Does not extinguish
– Not suppressed with fixation
Peripheral Central
What Controls Eye Movement?
• Choice– Fixation
• Reflex– Vestibulo-ocular
– Vestibular balance
• Coordination– Neural integrator
– Cerebellum
What Controls Eye Movement?
Choice
Reflex
Coordination
Understanding the System
Understanding the System Understanding the System
Spinning on that Dizzy Edge
Understanding the System Understanding the System
Vestibular Testing Vestibular Testing
• Visual fixation testing
• Vestibulo-ocular reflex
• Head impulse test
• Head shaking visual acuity
• Postural stability
• Hearing
Vestibular Testing
• Visual fixation testing
- White paper in front of nose
- Have patient look “through” paper
- Repeat with paper with writing 12 inches from nose
- Peripheral nystagmus unidirectional, fast toward damage
- Central not suppressed with fixation
Vestibular Testing
• Vestibulo-ocular reflex
- Have patient fixate on finger
- Ask patient to turn side to side
- Check for smooth tracking
- Ipsilateral failure with peripheral
- Intact with central vertigo
Spinning on that Dizzy Edge
Vestibular Testing
• Head impulse test
- Have patient fixate on nose
- Jerk face side to side irregularly
- Check for fixation and saccades
- Ipsilateral failure in peripheral vertigo
- Specificity over 90%
Vestibular Testing
• Head shaking visual acuity
- Have patient shake head
at 2-3 Hz
- Have them read at the same time
- Drop in 2 lines of acuity is positive test
- This helps detect bilateral vestibular dysfunction
Vestibular Testing
• Postural stability
- Romberg may be positive
- Gait should be stable in
peripheral vertigo
- Most central vertigo cannot walk without assistance
Vestibular Testing
• Hearing
- Gross test of hearing
- Tinnitus, roaring, and partial
hearing loss suggestive of peripheral
- Total hearing loss may be manifestation of stroke
How Do You Trick Your Patient Into Having Nystagmus?
How Do You Trick Your Patient Into Having Nystagmus?
Just Say No
Spinning on that Dizzy Edge
70 yo with a chief complaint of dizziness
• Dizziness started suddenly
• Feels unsteady and is afraid she will fall
• Some nausea
• Right sided nystagmus on right gaze
• Left sided nystagmus on left gaze
• Can only walk with support
70 yo with a chief complaint of dizziness
• Visual fixation testing Does not extinguish
• Vestibulo-ocular reflex Normal
• Head impulse test Normal
• Head shaking visual acuity No change
• Postural stability Bad with eyes open/closed
• Hearing Normal
Stroke
• Sudden onset
• Bi-directional nystagmus
• Postural instability with eyes open
60 yo with a chief complaint of dizziness
• Symptoms worsening over last 3 hours
• Has some nausea
• Feels like she might fall
• Recent URI
• Horizontal nystagmus
• Can walk without assistance
60 yo with a chief complaint of dizziness
• Visual fixation testing Extinguishes
• Vestibulo-ocular reflex Normal
• Head impulse test Abnormal
• Head shaking visual acuity Change of 1 line
• Postural stability Bad with eyes closed
• Hearing Normal
Vestibulitis
• Onset is abrupt, peaking over first day
• Symptoms last for weeks to months
• Bell’s Palsy of the XIIIth nerve
How do you treat it?
Spinning on that Dizzy Edge
Vestibulitis
• Treat like Bell’s Palsy
• Limit symptomatic treatment
55 yo with a chief complaint of dizziness
• Symptoms while getting bowl off shelf
• Symptoms last less than a minute
• Asymptomatic when still
• Nausea and vomiting
• Upward rotatory nystagmus
• Can walk without assistance
55 yo with a chief complaint of dizziness
• Visual fixation testing Extinguishes
• Vestibulo-ocular reflex Normal
• Head impulse test Normal
• Head shaking visual acuity Change of 1 line
• Postural stability Bad with eyes closed
• Hearing Normal
Dix-Hallpike Maneuver
Dix-Hallpike Maneuver
BPPV
• Latency
• Symptoms less than 1 minute
• No symptoms with no movement
• Most commonly involves posterior semi-circular canal
How do you treat it?
Spinning on that Dizzy Edge
Epley ManeuverWhy is the head impulse test
negative in BPPV?
Vestibular Testing 59 yo with a chief complaint of dizziness
• Has been present for 2 hours
• Has had similar symptoms in the past
• Some roaring in his right ear
• Nausea and vomiting
• Horizontal nystagmus
• Can walk without assistance
59 yo with a chief complaint of dizziness
• Visual fixation testing Extinguishes
• Vestibulo-ocular reflex Abnormal
• Head impulse test Normal
• Head shaking visual acuity No change
• Postural stability Bad with eyes closed
• Hearing Decreased on the right
Meniere’s Disease
• Recurrent vertigo
• Lasts 20 minutes to a few days, most commonly a few hours
• Hearing loss with a roaring tinnitus
What is your concern if it was preceded by trauma?
Spinning on that Dizzy Edge
Perilymph Fistula
• Presents just like Meniere’s, but with trauma
• Predisposes to meningitis
What is your concern if it isn’t recurrent?
Labyrinthitis
• Like vestibulitis, but involving labyrinth, as well
• Treat like Bell’s Palsy
How good is this stuff? Can I send anyone home? Or will they all just die some horrible stroked-
out death?
Some of the Data
• Prospective study of 43 patients in ED– Negative head impulse test in 96% of patients
with CVA
– 100% sensitive for peripheral disease
Neurol 2008 70: 2378-2385
Some of the Data
• Prospective study of 24 patients with acute severe dizziness – 25% had stroke etiology
Acta Neurol Scand 1995 91(1): 43-48
Some of the Data
• Metanalysis – 50% of stroke patients have dizziness as a
symptom
– 3% of dizzy patients have a stroke
– <1% of patients with a stroke had isolated dizziness when examined thoroughly
Neurol Clin 2012 30(1): 61-74
Spinning on that Dizzy Edge
Some of the Data
• Retrospective review of 240 cases of cerebellar infarct– 46% had unilateral nystagmus
– 71% could not walk without support
– 84% of all cerebellar infarcts had either direction changing nystagmus or inability to walk
Neurol 2006 67: 1178-1183
Some of the Data
• Retrospective study of 31,159 patients d/c with dizziness or vertigo– Same odds of CVA regardless of d/c dx
– < 1/500 had CVA at one month
Stroke 2006 37(11): 2484-2487
My Recommendations
• Get a good history– Abrupt onset with ongoing symptoms = CVA
– Symptoms < 1 minute = BPPV
– Symptoms for hours = Meniere’s or TIA
– Symptoms for days = vestibulitis or mass
My Recommendations
• Get a good history
• Do a good exam– Inability to walk = CVA
– Multidirectional nystagmus = CVA
– Failure to fixate = CVA
– Any other neuro findings = CVA
– Positive head impulse suggests peripheral
– Tinnitus suggests peripheral
– Subacute onset suggests peripheral
My Recommendations
• Get a good history
• Do a good exam
• Consider the past medical history– Atrial fibrillation
– Prior stroke
– Vascular disease
My Recommendations
• Get a good history
• Do a good exam
• Consider the past medical history
• Understand the limitations of your ED eval– CT scan in stroke