Inpatient Evaluation of The “Dizzy” Patient Jaclyn Laine DO, APBN OhioHealth Neurological Physicians

Objectives: Identify key history leading to more accurate diagnosis Distinguish clinical features of central versus peripheral etiology Determine the “red flag” symptoms for pathologic vertigo

Anatomy Peripheral Vestibular System Vestibular aparatus: semicircular canals, utricle saccule and CN VIII- vestibular nerve Central Vestibular System Vestibular nuclei at the ponto-medullary junction, cerebellum, midbrain

Consensus Definitions for Vestibular Symptoms Vertigo The sensation of self -motion with no motion is occurring or distorted self motion during normal head movements Dizziness The sensation of disturbed or impaired spatial orientation without a false or distorted sense of motion Unsteadiness Feeling of being unstable without a particular directional preference Oscilopsia The false sense that the visual surround is oscillating

Timing is the most important detail ! Acuity Acute or chronic Provoking nature Spontaneous or positional Episodic or prolonged Seconds, minutes, hours, days Fluctuations or no symptoms between episodes

Key Points in Past Medical history History of migraine With aura or vertigo induced by movement in surrounding Atherosclerotic risk factors CAD, known orthostasis Head trauma Medications: lithium, TCA’s ototoxic antibiotics, alcohol, AED’s

Features pointing towards central etiology: Exam with postural and gait instability Nystagmus can be any direction, however Sometimes reverses direction when patient looks in the direction of slow component Features pointing towards peripheral etiology Aural fullness, Hearing loss, tinnitus Sensation of instability - not wanting to walk Exam with normal posture and gait Nystamgus torsional horizontal, not purely vertical, doesn’t reverse direction

Vertigo is not continuous for more than a few weeks. Even with permanent lesions the central nervous system adapts to the defect so that vertigo subsides over several weeks. Constant dizziness lasting months is usually psychogenic, not vestibular. Some patients who say they have constant dizziness for months actually mean that they are susceptible to frequent episodic dizziness.

Common Categories of Vestibular Symptoms Acute, Spontaneous and prolonged (Acute vestibular syndrome) Episodic, positional (BPPV and central mimics) Episodic spontaneous (Vestibular migraine, Meniere's, TIA ) Chronic unsteadiness -with/without oscilopsia (Oscilopisa at rest – nystagmus brain stem lesion) (Oscilopsia with head motion - bilateral vestibular failure)

New onset dizziness Common causes and dangerous Mimis BENIGN Dangerous Mimics Seconds to hours- episodic BPPV TIA, Cardiac Arrythmia Orthostatic hypotention MI, PE, GI bleed Reflex syncope Aortic dissection, atrial myoxma Days to weeks- continuous Viral labrynthitis Brainstem/ cerebellar stroke Vestibular neuritis Bacterial labrinthitis/mastoiditis Medication toxicity Herpes zoster oticus Anticonvulsants Brainstem encephalitis Wernicke Syndrome Toxic – lithium, etoh withdrawal CO exposure

Key points Vestibular dizziness is always exacerbated or provoked by head movement At least in the acute phase No matter if peripheral or central in origin Clear reproducible triggers for non-exertional vestibular symptoms generally indicate a benign cause Not all patients with new onset seizure require MRI

Case #1 25 year old woman presented with recent episodic dizziness and headache. This occurred spontaneously one or twice a week during the prior 6 weeks. Lasting 5-10 minutes. No associated neurologic symptoms were present. The pain was located behind the left year and present throughout the last six weeks without variation of severity. Personal history of episodic migraine holocephalic, nausea, throbbing, dizziness, family history of migraine, no history of vascular risk factors

Case Considerations Sounds like Vestibular migraine Young, female, personal history of migraine with “dizziness” However non-flucuating continuous head pain with referral to ear? What questions are missing? History of trauma History or recent illness, fever, ear drainage History of aural fullness, tinnitus hearing changes

Further questioning Reveals head and neck trauma from carrying a mattress about 2 months ago Continuous headache and lack of fluctuating points to a fixed structural pathology Imaging CTA head and neck with attention to temporal bones looking for mastoiditis, vascular structural pathology Imaging revealed a vertebral artery dissection

Quick Tips Protective P’s If old and recurrent Periodic, Prolonged Recurrent Stereotyped episodes over years If symptoms are acute/subacute Painless IF painful Red flags: sudden < 30 minutes, severe, sustained >72 hours

Points to Remember Deadly D’s Indicating vascular brainstem symptoms Diplopia Dysarthria Dysphagia Dysmetria ( clumsiness) Dysethesias (specific facial numbness) Drop attacks Down is up distortions ( room inverted) NO dyspnea ( cardiopulmonary) NO deafness ( vascular inner ear)

Case 2# 71 year old man presented with several months of episodic spinning, lightheadedness and imbalance Last episode occurred for 10 seconds when her got our of been. He sat down and felt normal within in 20 seconds He has been awakened by a spinning sensation A more recent spell was described at lightheadness with standing in line at the grocery store Neurological Exam and imaging normal, cardiac work up with Echo and EKG normal Dix halpike showed nystagmus with left head position Vestibular rehab improved symptoms, however continued to have symptoms walking

His continued symptoms warranted investigation and with orthostatic vital signs were not significant Tilt table revealed BP to 75 systolic with normal HR and BP Blood pressure meds adjusted Low dose fludrocortisone Behavioral strategites This illustrates that the original history described two types of “dizziness”

Case 3# 26 year old male presents with 3 days of recurrent, severe dizzy episodes with ear fullness and sensitivity to sound. some last for 30 seconds, some for 10 minutes. This is brought on by exertional activities. He moved to a new apartment in the last week.

Perilymph Fistula Episodic dizziness without true vertigo Associated with heightened hearing or loss of hearing Provoked by coughing or vasovagal Caused by head trauma, heavy lifting, SCUBA Diagnosis: ENT, valsaval with nystagmus, MRI not usually helpful, temporal bone CT rules out other pathology, Treatment: ENT Strict bed rest Possible surgery

Case #4 51 year old woman who noted sensation of her right ear ‘being blocked’ this AM. Now has ringing and decreased hearing The room then began to spin wildly   She became diaphoretic, nauseated and vomited   The spinning lasted about 60 minutes, then abated   She now has a sensation of residual dysequilibrium several hours later When a patient presents with new onset seizures with a cluster seizures, this is still considered first time seizure and does not define epilepsy, or automatic indication for AED’s

Case #5 50 y/o woman suddenly feels overwhelming tilting sensation, feels her legs become rigid and abruptly falls to the ground Recovers to normal after a few seconds Prior history at age 43 of single episode of tinnitus with dizziness lasting several hours with complete resolution

Diagnosis in both cases Meniere’s Both are characteristic variants

Meniere’s   Two or more definitive spontaneous episodes of vertigo 20 minutes or longer Audiometrically documented hearing loss on at least one occasion   Tinnitus or aural fullness   Other causes excluded

Probable Meniere's One definitive episode of vertigo  Audiometrically documented hearing loss on at least one occasion  Tinnitus or aural fullness Other causes excluded

Treatment Diazide diuretic Strict low Na intake Vestibular suppressant Stress Reduction In severe cases surgical management

Eye movement testing A word on nystagmus. . . No one likes to interpret it High Points: Nystagmus that fatigues- peripheral Persistent downbeat- central Pathologic Gaze evoked nystagmus Vertical ( central) Asymmetric Present within 30 degrees of primary gaze

Case 6 65 year old female with history of mild imbalance and more episodes of vertigo when lying in bed at night. Examination shows: subtle downbeat nystagmus when gazine right and left Dix hallpike in both directions triggers downbeat nystagmus only Where is the most likely localization? A: cerebellum B:lateral semicircular canal C: vestibular nerve right D: saccule

Cerebellum Gazed evoke downbeat nystagmus Persistent positional downbeat nystagmus Despite central etiology- cerebellar lesions can cause prominent positional symptoms

Conclusions Initial history for subjective sensation and associated symptoms is key in establishing appropriate differential Always perform eye movement testing, coordination testing, and gait testing Timing of symptoms is more important than subjective description