1. Dizziness and Vertigo
Shawn Stepp, PA-C Central Maine Medical Center Emergency Department
We have all had the vague Dizzy patient in the office or the ED. And this can be one of the most difficult types of situations to know whether to send to the ED or to know what to do with them when they get there. So, my goals for today are to describe when to send to the ED, and once they are there what to do with them. This will be case based to hopefully make it more interesting.

2. Dizziness and Vertigo Primary resources:
Kattah, Talkad, Newman-Toker, Wang, Hsieh. HINTS to diagnose Stroke in the Acute Vestibular Syndrome: Three-Step Bedside Oculomoter Examination More Sensitive than Early MRI DWI. Stroke 2009; 40;
Nelson, JA. The Clinical Differentiation of Cerebellar Infarction from Common Vertigo Syndromes. Western Journal of Emerg Med Nov. 2009; vol x, no 4.
Asimos, Andrew, MD. THE DIZZY PATIENT. Lecture from the 38th Annual Michigan Emergency Medicine Assembly.
Kerber KA. Vertigo and Dizziness in the Emergency Department. Emerg Med Clin N Am 2009;27:39–50.
Tarnutzer AA. Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome. CMAJ 2011;183(9) :E
First of all, some primary resources. Notice the name of David Newman-Toker on here. He is one of the neurologist who developed the Head impulse test that we will be describing later as a pivotol test in the differentiation between a peripheral and central cause of vertigo.

3. Dizziness and Vertigo
When Dizzy is a Disaster: Cerebellar Stroke and vestibulobasilar insufficiency
Clinical presentation can resemble many other benign disorders
Main symptoms are non-specific Dizziness, N/V, headache
Important components of the neuro exam that help to make the diagnosis commonly omitted or abridged in the ED and the family practice office
Coordination, gait, and eye movement abnormalities can be subtle
Brain CT rarely identifies early-stage cerebellar infarction (only 26% of the time)
Morbidity includes brainstem compression and obstructive hydrocephalus
Here is the problem: dizziness is a very common complaint (2.6 million ED visits on av from ) and 97% of the time it is a benign d/o like BPPV. However, 3% have cerebellar infarction or vestibolobasilar insufficiency. The misdiagnosis rate is 35% and the mortality rate as high as 40%. There is a huge difference in disposition among patients with Benign paroxysmal positional vertigo, labyrinthitis, and stroke. So here is a patient I had a few months ago

4. Dizziness and Vertigo Case number 1
We will hit the highlights here. 78 yo M w/hx of CAD s/p CABG x 4 but w/ no hx of stroke who presents with acute onset of “the room spinning around me” since early this morning. It is now 14:00. He is able to tell me that he thinks it moves to the left. He has been very nauseous with this but has not vomited. It is much worse with any movement of his head. If he lays completely still, it slows down and basically goes away, but he still does not feel well. He cannot ambulate because any movement makes him so dizzy that he cannot walk. He has no other visual symptoms and he denies tinnitus, paresthesias, and weakness. He was able to get his own clothes on this morning with minimal assist from his wife.
Anything concerning in this history? He can’t walk
Anything reassuring? Worse with movement, almost goes away with no movement
What is going to be your money test in this patient? Dix-hallpike maneuver.

5. Dizziness and Vertigo
Video of Dix-hallpike:
Video of torsional upward beating nystagmus:
The posterior canal is the most commonly affected canal, and it is this canal that produces upward beating torsional nystagmus upon performing the Dix-Hallpike maneuver. This maneuver also uncovers which ear is the culprit: the nystagmus will be evoked when the affected ear is downwards. The intense portion of the provoked nystagmus is delayed in onset (5-10 seconds to start) and usually lasts less than a minute. They might feel residually “bad” or “nauseous” after and they can vomit. The nystagmus will decrease without any repeat movement

6. Dizziness and Vertigo
Dix hallpike: hold head 45 degrees to one side. Lower quickly with head degrees extended off the end of the bed.
Results in BPPV:
torsional nystagmus generally upward beating and toward the side of the semicirular canal problem. The nystagmus will occur when the affected ear is closest to the ground
Latency of onset (usually 5–10 seconds, but can be up to 40 secs)
The nystagmus are fatigable (generally less than a minute)
Nystagmus often reverse direction/rotation when sitting up quickly
What is the treatment for BPPV?

7. Modified Epley Maneuver
So my patient had provoked rotatory nystagmus to the left with a latency of about 5 seconds that lasted about 30 seconds before calming down.
What is the treatment of BPPV? Pretty straightforward: modified Epley maneuver (which patient can do on their own and I will often give the patient this handout from uptodate)
Performed the Epley maneuver and right after, he did not feel well….but 20 mins later he was able to walk without any vertigo and was discharged with PCP f/u. As an aside: there is no place for treatment with meclizine in these patients. It is not effective and can cause
If you see this patient in the office, do you send them to the ED? no

8. Dizziness and Vertigo
Benign Paroxysmal Positional Vertigo: Most common cause of vertigo
Lifetime prevalence of 3.2% in females and 1.6% in males
Of 100 unselected elderly patients, a prevalence of 9% was reported
Median duration of two weeks
Female preponderance likely reflects the association of migraine with BPPV
Association of BPPV with hypertension and hyperlipidemia
Von Brevern et al., 2006
If you see this patient in the office, do you send them to the ED? no

9. Dizziness and Vertigo Case number 2
What’s concerning about this patient?
Can’t walk. Diplopia
What’s the differential?
Cerebellar stroke, posterior circulation problem like vertebrobasilar insufficiency, labyrinthitis/vestibular neuritis, migrainous vertigo, and Meniere’s disease.
-An 80 yo F who presents with “I’m so dizzy I can’t walk.” Acute onset at 6 am when she awoke and it is now 10 am. She has been unable to walk without someone helping her. “I run into the wall.” She leans to the left. She is nauseous but has not vomiting. She’s not sure if the room is spinning around her. She says “I think I am spinning around the room.” The vertigo is present when she closes her eyes (though it does seem to get a little better). It has been unrelenting since she woke up. Movement makes it worse, but not much worse. Her bilateral legs feel weak but she denies any focal weakness. She can actually move her legs, they simply feel week. She denies paresthesias. She does have diplopia that resolves when covering one eye.
If you see this pt in the office, do you send to the ED?
This patient was actually sent in by her pcp.
DDX : Cerebellar stroke, posterior circulation problem like vertebrobasilar insufficiency, labyrinthitis/vestibular neuritis, migrainous vertigo, and Meniere’s disease. NOT BPPV B/c unrelenting and not particularly worse with movement.
BPPV is not really in the differential as this is clearly not the diagnosis.

10. Dizziness and Vertigo
A note on anatomy (thanks to Dr. Aimos for this slide). To adequately test the cerebellum, you need to test limb ataxia, truncal ataxia, and ocular movements. Limb ataxia (finger to nose, heel to shin, ambulation-which is likely the most important, writing, pill rolling). Truncal ataxia-sitting up and walking. Ocular movments (HI, nystagmous, diplopia, EOMI, visual fields) . 4th ventricle-can end up with obstructive hydrocephalus.
Green-floculonodular node.

11. Dizziness and Vertigo
True, unrelenting vertigo= acute vestibular syndrome.
The HINTS test
HI=head impulse
N= nystagmus
TS= Test of skew
HINTS- for acute vestibular syndrome.
Verical nystagmus- bad.
Direction changing nystagmus- bad
Test of Skew. Vertically disconjugate gaze. Alternating cover test. Pt’s looks at nose and have them look at eyes. Rapidly remove hand and watch to see if one eye realigns. Pt w/abnormal vertical skew often have Diplopia.
Kattah, Talkad, Newman-Toker, Wang, Hsieh. HINTS to diagnose Stroke in the Acute Vestibular Syndrome: Three-Step Bedside Oculomoter Examination More Sensitive than Early MRI DWI. Stroke 2009; 40;
More sensitive than MRI

12. Dizziness and Vertigo http://emcrit.org/misc/posterior-stroke-video/
Dr. David Neumen Toeker performing and normal Head impulse test. HI= should be abnormal with labyrinthitis/vestibular neuritis, migrainous vertigo, Meniere’s disease and even BPPV (as long as they are currently having symptoms). A normal test (which is what is in the video) with vertigo is bad.
Vestibular ocular reflex does not traverse the cerebellum.

13. Nystagmus Good (peripheral cause) Bad (central cause likely)
Horizontal or rotational. Never purely vertical
Vertical (though can be horizontal)
Delayed onset with movement (5-40 secs)
Unrelenting
Inhibited by fixation
Fatigable
Unidirectional
Direction changing (though can be unidirectional)
I have not mentioned direction changing nystagmus yet. Direction changing nystagmus occur when the patient looks to the right, the fast phase is to the right. When they look to the left, the fast phase is to the left. Such the nystagmus that change directions according to the patient’s gaze. This was found to be 56% sensitive for cerebellar infarction, though unidirectional nystagmus does not rule out a cerebellar stroke.

14. Dizziness and Vertigo
Test of Skew: Vertically disconjugate gaze. Pt looks at examiner’s nose. If one eye drifts up or down, this is a positive test and likely indicates a central cause of the vertigo.
Alternating cover test to vertical allignment: If the patient does not have an obvious vertically disconjugate gaze, cover one eye. Rapidly remove hand and watch to see if one eye realigns. Pt w/abnormal vertical skew often have Diplopia.
. Vertically disconjugate gaze. Alternating cover test. Pt’s looks at nose and have them look at eyes. Rapidly remove hand and watch to see if one eye realigns. Pt w/abnormal vertical skew often have Diplopia.

15. Dizziness and Vertigo
Head impulse normal and she had vertical skew deviation of her gaze.
Emergent treatment: she woke up with the symptoms, so outside the potential treatment window for t-PA. So, ASA.
Talk to neurology and this patient needs a MRI/MRA. Have to get the MRA portion to eval the vertebrobasilar vessels.
Small cerebellar stroke affecting the abduscens nucleus and the vestibular nucleus causing diplopia and gait instability. Thought to be likely embolic. She did well with rehab and PT. Plavix.
Back to my patient.

16. Cerebellar and brainstem strokes
3% of patients presenting to the ED with dizziness have a cerebellar stroke.
20% of all strokes are in the vertebrobasilar distribution
Grad and Baloh (1989): 62% had isolated vertigo without associated neurological deficits, and 19% had isolated vertigo as first TIA
Several minutes (3-4 min) duration of vertigo and not provoked by movement is always suspicious for TIA
These strokes can be devastating causing herniation and death.
They are often preceded by TIAs, represented by isolated vertigo, as noted above
This does not mean that every dizzy patient gets an MRI/MRA.
Here is a case from the Dr. Aimos that was referred to them as experts for possible litigation. 55 yo M who presented with HA, dizziness, and nausea. All pretty nonspecific. PE included finger to nose and heal to shin that was normal. Though he stumbled some with walking, he was actually able to get up and walk around with support from his companion. Really wanted to go home. CT read as possible small occipital stroke in the middle of the night. Placed on aspirin and asked to follow up in the am. Was actually a cerebellar stroke along the 4th ventricle. Came in 20 hrs later obtunded. Herniated and died in 24 hrs.
A few things wrong with this obviously. Gait disturbance and new stroke and sent home….but this case makes us pucker a bit as it should.
Cerebellar strokes can compress the brainstem and herniate. If compression of 4th ventrical or possibility in the future, call neurosurgery: suboccipital craniectomy and can have great outcomes.
Headache not uncommon in post circulation stroke (40% with ischemic stroke). Typically in occipital and proximal cervical region.
50 yo Male with new onset of headache, esp occipital, don’t call it a migraine.

17. Characteristics of Vertigo
Duration
Etiology
Seconds
BPPV
Minutes
VBI, TIA
Hours
Meniere’s
Days
Vestibular Neuritis, Vertiginous Migraine, Brainstem or cerebellar stroke
So, here’s a nice little chart to help you differentiate between the different causes of vertigo. As you can see, anything above a minute of unrelenting vertigo unrelated to movement is concerning and recquires HINTS testing.

18. Characteristics of Vertigo
Good (peripheral)
Bad (likely central)
Positional (provoked)
Not positional
Lasts less than a minute unless provoked again
Minutes to hours
No associated neurologic deficits (though 62% of strokes/TIAs also had no associated neuro deficits.
Neuro deficits (always do finger to nose, heal to shin, fine motor, etc.)
HI=abnormal
N=rotational or horizontal
TS=no vertical skew deviation
HI=normal
N=vertical (though can be horizontal)
TS=vertical skew deviation
So, here’s a nice little chart to help you differentiate between the different causes of vertigo. As you can see, anything above a minute of unrelenting vertigo unrelated to movement is concerning and recquires HINTS testing.

19. Vertebrobasilar insufficiency
Usually from atherosclerotic disease, but 1/5 of infarcts may be cardioembolic
Causes episodic, spontaneus vertigo and neurologic symptoms (gait disturbance often) of abrupt onset in older patients that is often precipitated by a specific movement, likely extending the neck
A quick word on vertebrobasilar insufficiency since I do not have a case of this. Long and short. If you cannot provoke the vertigo in an elderly patient and definitively diagnosis it as vertigo, it should be treated as a TIA and imaging of the vertebrobasilar arteries should be performed. MRI/MRA often overestimates the clot burden but is the best test we have right now. Duplex US for the vertebral arteries is being developed but is not standard practice like it is of the carotid arteries yet. Check with you institution.

20. Dizziness and Vertigo Case 4
A 45 yo F with an acute onset of severe vertigo (room spinning to the right) a/w nause and vomitting since 8 am. It is now 10 am. Position/movement makes it much worse but she is vertiginous and vomiting at rest. Unable to ambulate. Cannot open her eyes. No diplopia or other vision changes. No other neurologic symptoms.
What do you want to do?
Positional, so likely peripheral. Dix-hallpike produces rotational nystagmus to the right that seem to fatigue in about a minute…but the patients begins vomitting again and as soon as she does, the nystagmus return. She feels vertiginous throughout everything. Modified Epley is unsuccessful. What do you want to do next? HINTS. Head impulse test is markedly abnormal. Skew test is normal.

21. Dizziness and Vertigo
Nelson, JA. The Clinical Differentiation of Cerebellar Infarction from Common Vertigo Syndromes. Western Journal of Emerg Med Nov. 2009; vol x, no 4.

22. Dizziness and Vertigo
Head impulse test is markedly abnormal to the right, the hypoactive side. Remember, this test the vestibular ocular reflex that does not cross the cerebellum. As a result, this test is very reassuring. However, b/c of her inability to ambulate and intractable vomiting, she is admitted. MRI/MRA negative and diagnosed with vestibular neuritis/labyrnithitis. She slowly improves over the next week
Nelson, JA. The Clinical Differentiation of Cerebellar Infarction from Common Vertigo Syndromes. Western Journal of Emerg Med Nov. 2009; vol x, no 4.

23. Vestibular Neuritis/Labyrinthitis
Usually subacute in onset (increases over a few hours)
Remains at maximal intensity for 1-2 days.
Gradually resolves over a week or 2.
Can have hearing loss associated with it. Often have a preceeding or current URI. May have tinnitus.
HI-markedly abnormal. Skew test normal .
Usually Viral cause
Treatment includes BZDs, other antiemetics (maybe meclizine), and prednisone.
A quick word on vestibular neuritis- I will not spend much time on this as our primary concern today is differentiating it from cerebellar stroke.

24. Dizziness and Vertigo
Test Limb AND trunkal ataxia. If they cannot walk appropriately, must investigate further
Oculomotor testing (nystagmus especially). Diplopia is a bad sign
If positional vertigo: Dix-Hallpike and Epley
If acute vestibular syndrome, HINTS testing
So, final wrap up. Trunkal and limb ataxia must be tested. Get them up and walk around! If they cannot, you must look further. If acute vestibular syndrome (unrelenting vertigo), HINTS testing is very helpful. Do HI on everyone with dizziness and vertigo until you feel somewhat comfortable. Skew test is a bit more difficult in my experience to understand and interpret but is also worth trying.