1. Approach to the dizzy patient
By: Laurence Poliquin-Lasnier
R2 Neurology

2. What Dizzy means? Illusory movement of the environment (vertigo)
Lightheadedness
Imbalance
Pre-syncope
Vertigo is a symptom, not a diagnosis. It arises because of asymmetry in the vestibular system due to damage to or dysfunction of the labyrinth, vestibular nerve, or central vestibular structures in the brainstem.Vertigo is only one type of dizziness. Other disorders that present with dizziness include presyncopal faintness, disequilibrium, and nonspecific or ill-defined light-headedness. The initial approach to the patient who complains of dizziness is to localize the cause of the symptom into one of these broad categories.

3. approximately 40 percent of dizzy patients have peripheral vestibular dysfunction; 10 percent have a central brainstem vestibular lesion; 15 percent have a psychiatric disorder; and 25 percent have other problems, such as presyncope and disequilibrium

4. Questions to ask Constant or episodic Associated symptoms
Gradual vs sudden onset
Aggravating/alleviating symptoms
Duration and frequency of attacks if episodic
Triggers

5. Distinguishing vertigo from other types of dizziness
Time course
Vertigo is never continuous
The CNS adapts to the defect so that vertigo subsides over several wks

6. Distinguishing vertigo from other types of dizziness
Provoking factors
Certain vertigo occur spontaneously, while others are precipitated by maneuvers that change head position or middle ear pressure ( coughing, sneezing, or Valsalva maneuvers)
Positional vertigo and postural presyncope are both are associated with dizziness upon standing
Determine whether dizziness can be provoked by maneuvers that change head position without lowering BP or decreasing cerebral blood flow
Such maneuvers include lying down, rolling over in bed, and bending the neck back to look up

7. Distinguishing vertigo from other types of dizziness
Aggravating factors
All vertigo is made worse by moving the head
Many patients in the midst of a vertiginous attack are petrified to move
If head motion does not worsen the feeling, it is probably another type of dizziness

8. Key point
Any type of dizziness may worsen with position change but disorders such as benign positional vertigo only occur after position change

9. Causes of dizziness
Peripheral
Central
Systemic

10. Peripheral causes Hx Duration Associated symptoms Physical
Vestibular neuritis/labyrinthitis
Single prolonged episode
Days
Nausea, imbalance
Peripheral nystagmus, + head thrust, imbalance
BPV
Positionally triggered episodes
< 1 min
Nausea, ask for history of trauma
Positionally triggered burst of nystagmus
Ménière disease
May be triggered by salty food
hours
Unilateral ear fullness, tinnitus, hearing loss, nausea
Unilateral low frequency hearing loss
Vestibular paroxysmia
Abrupt onset, spont or positionally triggered
seconds
Tinnitus, hearing loss
normal
Perilymphatic fistula
Triggered by sound or pressure change or physical strain
Hearing loss, hyperacusis, ask for history of trauma
Nystagmus with change in pressure
Salt may change fluid volume in labyrinth

11. Vestibular Neuritis Young adults Severe vertigo of rapid onset
Nausea, vomiting, imbalance
Symptoms gradually resolve over several days
Probably viral etiology
Generally benign, self-limited course
? steroids

12. Benign paroxysmal positional vertigo
Most commonly recognized cause of vertigo
Calcium debris within the posterior semicircular canal (canalithiasis)
Brief spinning sensation brought on when turning in bed or tilting the head backward to look up
Dizziness is quite brief, usually secs, rarely mins
May be severe enough to halt activity for this duration
Dix-Hallpike maneuver can provide further evidence of its presence, but is positive in only 50 to 80% of patients
Natural hx of BPPV is one of repeated, brief vertiginous episodes that are predictably provoked and continue for wks or months

13. Ménière’s disease
Reccurent attacks of vertigo associated with auditory symptoms (hearing loss, tinnitus, aural fullness)
Attacks variable in duration, most last > 20 min
Severe nausea and vomiting
Progressive hearing loss
Bilateral ménière in 1/3 of patients
Caused by hydrolymphatic hydrops
Can get acute episodes of falling/being pulled to the ground caused by acute stimulation of otolith “otolithic catastrophes of Tumarkin”
No loss of consciousness

14. Vestibular paroxysmia
Brief episode of vertigo lasting seconds
No trigger
Thought to be 2ary to spontaneous discharges from damaged VIII cranial nerve

15. Vestibular fistula
Tear or defect in the oval window and/or the round window (membranes that separate the middle ear from the fluid-filled inner ear)
Changes in middle ear pressure will directly affect the inner ear, stimulating the balance and/or hearing structures and causing symptoms

16. Acoustic neuroma
Very rare to have vertigo as it is slow growing so that the CNS has time to adapt and compensate
Mostly unilateral hearing loss

17. Central Causes Hx Duration Associated symptoms Physical exam
Stroke/Tia
Abrupt onset
>24hrs vs minutes
Brainstem, cerebellar
Central nystagmus, focal neuro signs
Multiple sclerosis
Subacute onset
Min-wks
Unilateral vision loss, diplopia ataxia
Central, peripheral or positional nystagmus
Neurodegenerative disorder
Spontaneous or positionally triggered
Min-hours
ataxia
Central/ peripheral nystagmus, cerebellar, extrapyramidal, frontal signs
Basilar migraine
Onset with typical migraine triggers
Seconds to days
Headache, visual aura, photo/phonophobia
Peripheral/ central/ positional nystagmus
Familial ataxia syndromes
Acute-subacute, episodic type with stress, exercise
hours
Central/ positional
Vertebrobasilar insufficiency

18. Brainstem/cerebellar infarct
Vertigo is a common symptom in Wallenberg syndrome/PICA infarct
Associated with diplopia, horner, crossed pain & temp loss
Vertigo may be the only symptom in cerebellar infarct
Oculomotor testing can show:
1- Pure unidirectional nystagmus
2- Direction-changing gaze evoked nystagmus
3- Impaired smooth pursuit
4- Overshooting saccades

19. Multiple Sclerosis May be the initial symptom in 5% of patients
Can get almost any type of vertigo, including peripheral vertigo when plaque affects root entry zone of the vestibular nerve

20. Neurodegenerative disorder
Parkinson
Progressive supranuclear palsy
Multi-system atrophy
Progressive ataxia disorders
Dizziness in these patients often better clarified as imbalance

21. Posterior fossa structural abnormalities
Chiari malformation causes pressure on cerebellum
Unsteadiness of gait may be described as dizziness by patients
Vertigo is rare
Posterior fossa tumor (eg medulloblastoma, gliomas)

22. Migraine
Benign recurrent vertigo may be considered as a migraine equivalent
With typical migraine triggers
+ family history
Normal neuro exam
No progressive hearing loss

23. Familial ataxia syndromes
Spinocerebellar ataxia
Friedreich ataxia
Episodic ataxia
+ oscillopsia
Friedrich = nerbe degenration 2ary trinucleotide expansion, muscle, heart, db

24. Systemic causes Medications Hypotension, presyncope
Infectious diseases (eg.: syphilis, viral, bacterial meningitides & systemic infection)
Endocrine diseases (eg.: DB/hypoglycemia & hypothyroidism)
Vasculitis (eg.: collagen vascular disease, giant cell arteritis, drug-induced vasculitis)
Hematological disorders
Hyperventilation, panic attack

25. On exam: Postural vitals General physical exam General neuro exam
Neuro-otological exam

26. Neuro-otological exam
Ocular motor function testing
Look for spontaneous nystagmus or saccadic intrusions
Nystagmus suggests that the dizziness is vertigo
Gaze testing
Look for gaze-evoked nystagmus
Normal to have non-sustained nystagmus with gaze greater than 30 degrees
Vertical nystagmus that increases with lateral gaze localizes to craniocervical junction and midline cerebellum
Saccades: no fast and slow wave, square wave jerks, saccadic oscillations

27. Nystagmus Feature Central Peripheral Latency none 2-15 sec Duration
Fatiguability
+/- ++
Vertigo
Usually absent
Usually present
Fixation
No suppression
suppression
Direction
Vertical or horizontal, direction may change with head position
Unidirectional, Horizontal or rotatory, fast phase toward normal ear, increased with gaze in direction of fast phase
Central vertigo often less severe than peripheral vertigo

28. Neuro-otological exam
Smooth pursuit
Voluntary mvt of of the eyes used to track a target moving at a low velocity
Look for saccadic pursuit
May occur with early/mild cerebellar degenerative disorders as the only finding with minimal ataxia

29. Neuro-otological exam
Saccades
Fast eye mvts used to quickly bring the image of an object on the fovea
Shift gaze from one object to another under voluntary control
Slowing of saccades = lesion in pons/midbrain, oculomotor neuron or extra-ocular muscles
Overshooting saccades = ocular dysmetria, sign of cerebellar lesion
Undershooting saccades less specific and occur in normal people

30. Neuro-otological exam
Optokinetic nystagmus
Combination of fast saccadic and slow smooth pursuit observed in N people observing a moving object
Patients with severe slowing of saccades will not be able to generate OKN and will have their eyes pinned on one side
Vestibulo-ocular reflex suppression
Normal individual can fixate his thumb while pt being turned on himself
Will elicit nystagmus in pts who have impaired smooth pursuit

31. Vestibular nerve exam Head thrust test
When quickly unpredictably turn head of patient by 30 degree on side, eyes will go on opposite direction (vestibulo-ocular reflex) to continue to fixate target
Abnormal vestibulo-ocular reflex if observe corrective saccade bringing eyes back to target after head thrust
Sensitivity 71% and specificity 82%
Vol. 84, No. 2, February 2004, pp. 151-Optimizing the Sensitivity of the Head Thrust Test for Identifying Vestibular Hypofunction

32. Positional testing Dix-Hall-Pike Epley manoeuver
Burst of upbeat, torsional nystagmus triggered in patients with BPV by rapid change from erect sitting to supine head-hanging right or left
Epley manoeuver
More than 80% effective in treating patients with posterior canal BPPV

33. Epley Maneuver

34. Epley maneuver
Key feature is the roll-across in the plane of the posterior canal so that the clot rotates around the posterior canal and out into the utricle

35. Fistula testing
Test for it if patient reports sound or pressure induced dizziness
Pressing or releasing the tragus will trigger nystagmus
Other variant with valsava

36. Gait assessment Wide based gait
Acute vestibular loss may cause the patient to lean on the side of the affected ear

37. Auditory examination Otoscopy
Whisper test (stand behind to prevent lip reading and occlude/mask the non-tested ear by finger rub or occluding external auditory canal)
Whisper 3-6 numbers or letters
Normal if can repeat 50%
Weber: lateralizes to ipsi conductive impairment or contralateral sensorineural
Rinne: if bone conduction > air conduction = ipsi conductive hearing loss

38. Conclusion Clarify what dizzy means
Be patient as history is the most important part, physical is confirmatory
Peripheral vs central vs systemic causes
General physical and neuro exam
Neuro-otological exam
- Ocular mvts/nystagmus
- Head-thrust
- Dix-Hall pike