Learning objectives. 65 year old man with dizziness VERTIGO: THE GOOD, THE BAD AND THE REALLY BAD
VERTIGO: THE GOOD, THE BAD AND THE REALLY BAD Jennifer Simpson, MD Vascular Neurologist Neurohospitalist
Learning objectives Differentiate common cau...
VERTIGO: THE GOOD, THE BAD AND THE REALLY BAD Jennifer Simpson, MD Vascular Neurologist Neurohospitalist
Learning objectives Differentiate common causes of dizziness from central vertigo ! Implement new physical examination techniques into your practice. !
65 year old man with dizziness… Presents after 1 week of dizziness. Describes the “world spinning” ! Worse with movement ! Some nausea, no vomiting ! !
What is vertigo? Sensation of self-motion when no self-motion is occurring or the sensation or distorted self motion during an otherwise normal head movement ! Ok, so what is “dizziness?” ! The sensation of disturbed or impaired spatial orientation without a false or distorted sense of motion !
What else can be confused with vertigo? •
Unsteadiness –
The feeling of being unstable when seated, standing or walking without a particular direction preference.
•
Oscillopsia
•
Presyncope
•
Syncope
–
–
–
False sensation that the visual surround is oscillating Sensation of impending loss of consciousness Transient loss of consciousness due to transient global hypoperfusion characterized by rapid onset, short duration, and spontaneous complete recovery
What Questions Should We Ask Our Patients? Symptom Type: What do they mean by “dizzy” or “vertigo?” ! Symptom Timing: duration of vertigo, frequency of attacks, onset of symptoms !
What is the appropriate treatment? Dix-Halpike maneuver Epley maneuver ! Corticosteroids ! Antiviral with valacyclovir 500 mg BID x 7 days ! tPA (aka alteplase) ! !
HINTS !
Acronym to tall you that it is NOT a stroke
Head impulse Nystagmus ! Test of skew ! !
This has not been prospectively validated Sensitivity 91% ! Specificity 78% ! !
The Acute Vestibular Syndrome !
Is usually stroke or vestibular neuritis!
Provocative Maneuvers !
h-HIT ! AKA
head thrust, head impulse passive head rotation from a center to a lateral position as the patient fixes on a central target (like the nose) ! Can also displace head laterally first, then move to center (this is what I like to do) ! Rapid,
Vestibular neuritis !
h-HIT abnormal ! +
to the opposite side of fast phase of nystagmus
Unidirectional horizontal nystagmus ! Nystagmus increases with gaze in direction that nystagmus beats !
Can you unmask nystagmus? Blank sheet of paper Frenzel lenses ! Occlusive ophthalmoscopy ! !
! Looks
for spontaneous nystagmus of the optic disc that the direction is the opposite from what you see on exam
! Remember
!
Penlight cover test ! http://jnnp.bmj.com/content/suppl/2009/07/22/jnnp.
A 65 year old with dizziness For the last 3 days Describes “world spinning” and has to hold onto objects to stay upright ! Much worse with head movement like head turning or rolling over in bed ! Happens “all the time” ! !
Physical Exam !
https://www.youtube.com/watch?v=cZlXvRlxrRE
What is the appropriate treatment? Dix-Halpike maneuver Half-Somersault maneuver ! Corticosteroids ! Antiviral with valacyclovir 500 mg BID x 7 days ! tPA (aka alteplase) ! !
Provocative Maneuvers !
Dix Hallpike ! Don’t
do if there is spontaneous nystagmus called Nylen-Bárány maneuver ! https://www.youtube.com/watch?v=rtS2muvjFbM ! https://www.youtube.com/watch?v=1VWyPgfMuvM ! Also
A 65 year old with dizziness Started an hour ago Could not walk to car and had to call 911 ! Severe nausea ! Does not want to open eyes for an exam ! !
Physical Exam !
https://www.youtube.com/watch?v=6acupyev0-w
!
https://www.youtube.com/watch?v=zgqCXef-qPs
What is the appropriate treatment? Dix-Halpike maneuver Epley maneuver ! Corticosteroids ! Antiviral with valacyclovir 500 mg BID x 7 days ! tPA (aka alteplase) ! !
INFARCT !
Acronym to help you decide it is a stroke
Impulse normal Fast-phase alternating ! Refixation on cover test ! !
How often is dizziness in the ED a stroke? ! !
About 3-5% of the time. How about isolated dizziness? ! 0.7%
(Kerber KA 2006)
Associated central symptoms !
! !
About 29% can report episodes of vertigo up to 2 years before stroke
AICA can have hearing loss Headache or neck pain in 29-38% ! In
dissection:
" Pain
is sudden in 57% in 60% " >72 hours 100% " Severe
Stroke !
Usually other clues that tell you it is central ! Focal
sensory symptoms
! Dysarthria ! Dysmetira ! Horner’s ! Truncal !
ataxia
Some clues can go central or peripheral ! Hearing
loss dizziness ! About 29% can report episodes of vertigo up to 2 years before stroke ! Isolated
Vertebrobasilar TIA !
Duration is usually minutes to 1-2 hours ! Spontanous
!
abrupt onset
Usually includes some other posterior circulation symptom
Usual pathophys !
Usually vascular risk factors
!
Heart disease is unusual !
??? Repeated embolization
!
Highly unlikely
!
Small vessel occlusion Artery-artery emboli
!
Large vessel stenosis w/wo thrombosis
!
Dissection
!
Spondylotic compression of vertebral artery (RARE!)
!
!
?hypoperfusion
Imaging MRI is better than CT when looking for acute stroke (duh) ! MRI can be falsely negative (duh) !
