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Vertigo
2014-11-03T15:10:27Z
<p>Mchenier: </p>
<hr />
<div>== Background ==<br />
*Perception of movement (rotational or otherwise) where no movement exists <br />
*Pathophysiology <br />
**Mismatch or asymmetric activity of visual, vestibular, and/or proprioceptive systems<br />
*Must distinguish peripheral from central cause<br />
**Peripheral: 8th CN, vestibular apparatus<br />
**Central: Brainstem, cerebellum<br />
<br />
== Clinical Features==<br />
<br />
{| class="wikitable"<br />
|-<br />
| <br />
| '''Peripheral'''<br />
| '''Central'''<br />
|-<br />
| '''Onset'''<br />
| Sudden<br />
| Sudden or slow<br />
|-<br />
| '''Severity'''<br />
| Intense spinning<br />
| Ill defined, less intense<br />
|-<br />
| '''Pattern'''<br />
| Paroxysmal, intermittent<br />
| Constant<br />
|-<br />
| '''Aggravated by position/movement'''<br />
| Yes<br />
| Variable<br />
|-<br />
| '''Nausea/diaphoresis'''<br />
| Frequent<br />
| Variable<br />
|-<br />
| '''Nystagmus'''<br />
| Horizontal<br />
| Vertical or multidirectional <br />
|-<br />
| '''Fatigue of symptoms/signs'''<br />
| Yes<br />
| No<br />
|-<br />
| '''Hearing loss/tinnitus'''<br />
| May occur<br />
| Does not occur<br />
|-<br />
| '''Abnormal tympanic membrane'''<br />
| May occur<br />
| Does not occur<br />
|-<br />
| '''CNS symptoms/signs'''<br />
| Absent<br />
| Usually present<br />
|}<br />
<br />
==Diagnosis==<br />
===Algorithm===<br />
[[File:Vertigo_and_Dizziness.jpg]]<br />
<br />
===HINTS Exam===<br />
Can reliably^ distinguish peripheral cause from cerebellar/brain stem CVA in the Emergency Department population <ref>http://ec.libsyn.com/p/a/d/d/add761f2a2847ea5/hints-exam.pdf?d13a76d516d9dec20c3d276ce028ed5089ab1ce3dae902ea1d01c0873ed8cc5fe910&c_id=2502227</ref><ref>http://www.ncbi.nlm.nih.gov/pubmed/18541870</ref><ref>http://hwcdn.libsyn.com/p/1/c/d/1cd6b38a89c178a1/diff-of-vertigo.pdf?c_id=2502226&expiration=1380995436&hwt=0a8bc67ea910e018a1543ebea192f668</ref><br />
#Head Impulse Testing<br />
##Tests vestibulo-ocular reflex<br />
##Have pt fix their eyes on your nose<br />
##Move their head in the horizontal plane to the left and right<br />
###If reflex is intact their eyes will stay fixed on your nose<br />
###If reflex is abnormal eyes will move w/ their head and won't stay fixed on your nose<br />
##It is reassuring if the reflex is abnormal!(due to dysfunction of the nerve)<br />
#Nystagmus<br />
##Benign nystagmus only beats in one direction no matter which direction their eyes look<br />
##Bad nystagmus beats in every direction their eyes look<br />
###If pt looks left, get left nystagmus, if looks right, get right-beating nystagmus<br />
#Test of Skew<br />
##Vertical dysconjugate gaze is bad<br />
##Alternating cover test<br />
###Have pt look at your nose w/ their eyes and then cover one eye<br />
###When rapidly uncover the eye look to see if the eye quickly moves to re-align<br />
##If any of the above 3 tests are consistent w/ CVA obtain full work-up (including MRI)<br />
<br />
^Sensitivity (for posterior ischemic CVA):<br />
*HINTS = 100%?<br />
*MRI <48hrs after symptom onset = 83%<br />
*MRI >48hrs = 100%?<br />
*CT = 16%<br />
<br />
^Positive test = INFARCT for posterior stroke<br />
*Impulse Normal (abnormal indicates peripheral)<br />
*Fast-phase Alternates (saccades alternate direction)<br />
*Refixation on Cover Test<br />
<br />
== DDX ==<br />
#Vestibular/otologic <br />
##[[Benign Paroxysmal Positional Vertigo (BPPV)]] <br />
##Traumatic (following head injury)<br />
##Infection<br />
###[[Labyrinthitis]]<br />
###[[Vestibular Neuritis (Neuronitis)]]<br />
###Ramsay Hunt syndrome <br />
#Syndrome <br />
##[[Meniere Disease]]<br />
##Neoplastic <br />
##Vascular <br />
##Otosclerosis <br />
##Paget disease <br />
##Toxic or drug-induced: aminoglycosides <br />
#Neurologic <br />
##Vertebrobasilar insufficiency<br />
###Head turning causes vertigo, [[Diplopia|diplopia]], dysarthria, b/l loss of vision, syncope<br />
##Lateral Wallenberg syndrome <br />
##Anterior inferior cerebellar artery syndrome <br />
##Neoplastic: cerebellopontine angle tumors <br />
##Cerebellar disorders: hemorrhage, degeneration <br />
##Basal ganglion diseases <br />
##Multiple sclerosis <br />
##Infections: neurosyphilis, tuberculosis <br />
##Epilepsy <br />
##Migraine (basilar) <br />
##Cerebrovascular disease <br />
#General <br />
##Hematologic: anemia, polycythemia, hyperviscosity syndrome <br />
##Toxic: alcohol <br />
##Chronic renal failure <br />
##Metabolic <br />
###[[Thyroid Disease]] <br />
###[[Hypoglycemia]]<br />
<br />
==Work-up==<br />
#Glucose check <br />
#Full neuro exam<br />
#TM exam <br />
#?CT/MRI - if symptoms consistent with central cause<br />
<br />
==Management==<br />
=== Peripheral ===<br />
<br />
Symptomatic control<br />
#Antihistamines<br />
##Meclizine (antivert) 25mg PO QID<br />
##Diphenhydramine (benadryl) 25-50mg IM, IV, or PO q4hr<br />
#Anticholinergics<br />
##Scopolamine transdermal patch 0.5mg (behind ear) QID<br />
#Antidopaminergics<br />
##Metoclopramide 10-20 IV or PO TID<br />
<br />
Cause Reversal<br />
#Epley maneuver (see [[BPPV]])<br />
<br />
===Central===<br />
#R/O [[CVA]]<br />
#MRI<br />
#R/O Vascular insufficiency<br />
<br />
== Disposition ==<br />
*Most pts w/ peripheral vertigo can be discharged home<br />
*Most pts w/ central vertigo require urgent imaging and consultation while in the ED<br />
<br />
==See Also==<br />
*[[Dizziness]]<br />
*[[EBQ:HINTS_Exam]]<br />
*[[Cerebellar Stroke]]<br />
*[[Stroke syndromes]]<br />
<br />
== Source ==<br />
*Tintinalli<br />
<references/><br />
[[Category:Neuro]]<br />
[[Category:Featured]]</div>
Mchenier