r jeanmonod-aafp april dizzy kk lm rs.ppt on that dizzy edge disclosure rebecca jeanmonod, md,...

Spinning on that Dizzy Edge

Rebecca Jeanmonod, MD, FACEP

St. Luke’s Hospital

Department of Emergency Medicine


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?


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


• 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



• 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?


Vertigo


Psychiatric

Intoxicated

Presence of nystagmus

History of substance use

Postural hypotension

Other neuro findings


• Patient was in a car accident

• Symptoms present regardless of position

• Has had persistent dizziness for months


• 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?


Vertigo


Psychiatric

Intoxicated


Psychiatric history

No other neuro findings

Non-physiologic course


• Patient was moving bowels and felt dizzy

• Had blurry dark vision for a minute or two

• Now feels better



• 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?


Vertigo


Psychiatric

IntoxicatedTransient symptoms

Seated or standing


No other neuro findings


• Symptoms worsening over last hour

• Has some nausea

• Feels like she might fall

• Recent URI


• Symptoms worsening over last hour

• Has some nausea


• Recent URI

• Horizontal nystagmus

• Can walk without assistance

What is this?


Vertigo


Psychiatric

Intoxicated

Nystagmus

Symptoms worse with movement

Not positional

NystagmusRapid onset

Supine sxs

Disequilibrium

Near syncope

Vertigo

Psychiatric

Intoxicated

Comorbids

+/-

+/-

- - -

++

+/-

+

+

+

+

-

-

-

+

+

++/-

+/-


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


• Vestibulitis

• Labyrinthitis



• Migrainous

• Stroke


• Tumors


• Drugs

CentralPeripheral


• Vestibulitis

• Labyrinthitis



• Migrainous

• Stroke


• Tumors


• Drugs

CentralPeripheral


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?


What You’ve Heard About Nystagmus


• Peripheral– Extinguishes

• Central– Does not extinguish

Peripheral Central



– Suppressed with fixation


– Not suppressed with fixation

Peripheral Central




– Better with eyes closed



– No difference with eyes closed

Peripheral Central





– Horizontal or rotatory nystagmus only




– Vertical nystagmus

Peripheral Central





– Horizontal or rotatory nystagmus only

– Severe or sudden symptoms




– Vertical nystagmus

– Mild or insidious symptoms

Peripheral Central


What’s True About Nystagmus





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


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


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



• 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


• 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


• Symptoms worsening over last 3 hours

• Has some nausea


• Recent URI




• Visual fixation testing Extinguishes


• 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?


Vestibulitis

• Treat like Bell’s Palsy

• Limit symptomatic treatment


• Symptoms while getting bowl off shelf

• Symptoms last less than a minute

• Asymptomatic when still

• Nausea and vomiting

• Upward rotatory nystagmus






• Head shaking visual acuity Change of 1 line


• 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?


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





• Vestibulo-ocular reflex Abnormal


• Head shaking visual acuity No change


• 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?


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


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


• Do a good exam

• Consider the past medical history– Atrial fibrillation

– Prior stroke

– Vascular disease

My Recommendations


• Do a good exam

• Consider the past medical history

• Understand the limitations of your ED eval– CT scan in stroke

– CT scan for posterior fossa


My Recommendations


• Do a good exam

• Consider the past medical history

• Understand the limitations of your ED eval

• Treat symptoms gently– Antihistamines

– Benzodiazepines

– Anticholinergics

Thank You

For Your Time and Attention

r jeanmonod-aafp april dizzy kk lm rs.ppt on that dizzy edge disclosure rebecca jeanmonod, md,...

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