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64. Vertigo: “You Spin Me Right Round Baby Right Round”
Keywords
VertigoVertebrobasilar syndromeAcute vestibular syndromeNystagmusBenign paroxysmal positional vertigoVestibular neuronitisLabyrinthitisCase
Pertinent History
This patient is a 45-year-old male physician who was doing some paperwork in his office when he developed sudden, severe debilitating vertigo. He was found on the office floor by a colleague. He was complaining of a severe spinning sensation. He was actively vomiting at the time. He cannot recall anything that might have provoked the event. He appeared very stoic and had trouble answering questions. He was completely unable to ambulate or sit in an upright position. He denied headache, chest pain, numbness, tingling or overt weakness.
Physical Exam
Vitals: T 98.5 °F/36.9 °C, BP 160/98, P 110, RR 16.
General: Alert and oriented × 3, male in severe distress.
Head: Atraumatic.
Ears: within normal limits.
Eyes: Pupils equal, round and reactive to light, direction-changing nystagmus noted on exam.
Neck: Nontender, trachea midline; thyroid is normal.
Lungs: Bilaterally clear to auscultation.
Heart: S1/S2 increased rate with regular rhythm. No murmurs.
Abdomen: Soft, non-tender/non-distended, bowel sounds present, no mass or bruit.
Skin: Warm and dry with no rashes.
Neuro: Cranial nerve exam.
III, IV, VI (eye movements) – Significant direction-changing nystagmus.
V (facial sensory) – Normal
VII (facial motor) – Normal
VIII (auditory) – Normal
XI (glossopharyngeal) – Symmetrical palate movement.
X (vagus) – Normal
XI (accessory) – Normal
XII (hypoglossal) – Tongue protrudes to midline.
Speech: Mild slurring of speech.
Reflexes: 2+ bilaterally.
Sensory: Grossly intact.
Motor: Upper extremity strength is 5/5 bilaterally; Lower extremity strength is 5/5.
Pronator drift: Unable to perform.
Tandem gait: Unable to stand.
Romberg: Inability to maintain balance even with eyes open.
Finger to nose/heel to shin: Left-sided abnormality compared to the left.
Rapid alternating movements: Abnormal coordination.
Nystagmus: Nystagmus is horizontal and bidirectional.
Past Medical History
None
Social History
Alcohol: Social use
Tobacco: None
Drugs of abuse: Denies
Family History
Coronary artery disease
Pertinent Test Results
CT Scans and MRI
Images courtesy of Colin Kaide, MD and Michael Dick, MD
ED Management
The patient was brought to the ED from his office on an ED cart. He had persistent vomiting and profound vertigo with nystagmus. He was given Ativan, Phenergan, and Zofran with little relief of symptoms. He had a CT scan that was normal. He was sedated and taken for immediate MRI/MRA. The MRI showed and acute right cerebellar infarct and the MRA showed a vertebral artery dissection on the right side. He was given repeat doses of medication for nausea and vertigo but they were not particularly effective. He was transferred to the main campus hospital to be admitted to the neurology service.
Learning Points
Priming Questions
- 1.
What are the most common etiologies of vertigo in patients presenting to the Emergency Department?
- 2.
What provocative testing and imaging are required for patients presenting with vertigo?
- 3.
What is the Head Impulse, Nystagmus, and Test of Skew (HINTS) exam and how can it contribute to the evaluation of vertigo in the ED?
Introduction/Background
- 1.
Dizziness and vertigo account for about four million Emergency Department (ED) visits annually in the United States [1].
Between 160,000 and 240,000 (4–6%) are caused by cerebrovascular disease [1].
Approximately, one quarter of vertebrobasilar stroke patients had at least one transient neurologic symptom within 3 months prior to stroke [2].
In one small sample, 42% (21/50) had attacks with an isolated nonfocal symptom that was not considered typical transient ischemic attack (TIA)-like, and neuroimaging confirmed acute infarction in four of them. Vertigo was the most common of these non-focal symptoms [2].
- 2.
Elderly patients and “dizziness.”
Most common ED complaint in patients over 75 years old; up to 20% report symptoms significant enough to interfere with activities of daily living [2].
Chronic: Average five visits without resolution.
- 3.
The first step is to differentiate the complaint of “dizziness .” Since dizziness can mean anything the patient wants it to mean, it must be more precisely described to categorize it as one of the following:
Light-headedness: The feeling of passing out. Common phrases used to describe this feeling include:
“Lightheadedness.”
“Going to pass out.”
“Swimmy-headed.”
“Stood up too fast.”
True balance problems: Often described as falling to one side or not being able to coordinate movements. This can be a true ataxia representing posterior fossa disease.
Vertigo: The sensation of perceived motion, typically spinning but may also be described as swaying, tumbling, or tilting [3–5].
Nonspecific vague complaints. You will never figure this out! Ensure it is not something dangerous and send them back to their family doctor.
Physiology/Pathophysiology
A complete review of the vestibular organs and vestibulo-ocular interface is beyond the scope of this chapter. Know that the vestibular organ consists of three semi-circular canals and two otolith structures located in the inner ear that detect angular and linear acceleration, respectively. The movement of fluid (endolymph) contained within these structures activates or inhibits hair cells which in turn convey information to the cerebral cortex. These organs interface with the visual system and play a significant role in balance [6].
In turn, dysfunction of the central component of the system occurs in the vestibular structures in the brainstem or cerebellum. It is usually caused by an interruption in blood flow to those areas.
- 1.
Characteristics of PERIPHERAL Vertigo [7].
Acute onset, intense spinning, swaying with nausea, vomiting, diaphoresis aggravated by change in position.
Fatigable, unidirectional nystagmus inhibited by fixing on an object.
Otic symptoms sometimes present (pain, tinnitus, occasionally decreased hearing).
No central focal examination findings.
- 2.
Characteristics of CENTRAL Vertigo:
Gradual onset (but can be sudden with acute loss of blood flow), less intense with mild peripheral symptoms.
Nonfatigable, direction-changing nystagmus, uninhibited by eye fixation.
Vertical nystagmus (almost always central – may be seen in anterior canal benign paroxysmal positional vertigo (BPPV)) [8].
Focal cerebellar or brain stem findings such as dysmetria, dysdiadochokinesia, and gait ataxia [9].
Nystagmus
Published with kind permission of © Colin G. Kaide 2019. All Rights Reserved
The direction of the nystagmus is described by the fast component, which generally moves away from the side of the lesion. The fast component of the nystagmus is a cortically-mediated correction of the deviated direction of gaze. When in doubt about the direction of the nystagmus, use your smart phone camera in the slow-motion setting. It is easy to tell when the image is slowed.
Making the Diagnosis
Differential Diagnosis
Benign Paroxysmal Positional Vertigo (BPPV).
Meniere’s Disease.
Vestibular Neuronitis.
Labyrinthitis.
Cerebrovascular Accident (CVA).
Transient Ischemic Attack (TIA).
Vertebrobasilar Insufficiency (VBI).
Intracranial Mass.
Intracranial Hemorrhage.
- 1.
Determine if this vertigo is amenable to this algorithmic approach. The types of patients in whom the algorithm works are those with acute vestibular syndrome (AVS) . Patients with light-headedness or the feeling of fainting when standing can be excluded immediately from this algorithm.
Determine that the patient has an acute vestibular syndrome.
This is an acute, persistent vertigo lasting for at least 24 hours to several weeks with associated nausea or vomiting, head motion intolerance, gait unsteadiness, and nystagmus. It accounts for 10–20% of ED “dizziness” presentations. It is typically peripheral in 80% of cases and central in ~20% [10]. These patients will have symptoms while they are being seen in the ED.
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