Dizziness

1
Dizziness Vertigo

• Moritz Haager
• Oct 16, 2003

2
WADO

• 111 yo female presents to the ED with the
  complaint of feeling weak and dizzy all over
• How do you approach this?
• What are some of the key questions you should ask?

3
Objectives

• Clearly define terminology
• Dizziness
• Vertigo
• Syncope pre-syncope
• Examine the differential diagnosis for each
• Look at what tests are useful
• Look at what drugs are useful when
• Develop an approach to the weak dizzy pt

4
Dizziness

• Causes of dizziness in a outpatient neurology
  clinic specializing in dizziness

5
Dizziness is not a medical term

• Breaks down into 4 general categories
• Vertigo
• e.g. BPPV
• Syncope or pre-syncope
• E.g. orthostatic hypotension
• Dysequilibrium syndrome
• Undifferentiated dizziness
• Psychogenic
• E.g. anxiety
• Systemic illnesses w/ malaise
• E.g. pyleonephritis, hypoglycemia
• Who-kows-whats-the-_at_ -is-going-on-here

6
The Dizzy History

• What do you mean by dizzy?
• Vertigo vs. pre-syncope/syncope vs.
  weakness/malaise
• What precipitates it?
• How fast does it come on? How long does it last?
• Are there any associated hearing changes?
• Is there any evidence of other neurologic
  abnormalities?
• What meds are you on, or have you been on
  recently?
• Any head trauma?

7
Dysequilibrium Syndrome

• Age-related degeneration of visual,
  proprioceptive, and vestibular systems
• Pts have great difficulty with getting about
  especially at night with diminished light
• Present to ED with hip fractures

8
Vertigo

• Definition
• The illusion or sensation of movement of the pt
  or the pts surroundings (aka the spins in EtOH
  intoxication)
• Usually 2o to pathological basis, but need to
  differentiate benign from sinister
• Start by differentiating peripheral vertigo from
  central

9
Anatomy for Dummies

• Semi-circular canals
• 3 semi-circular canals at right angles to each
  other to detect angular acceleration
• Crista ampullaris sensory organ
• Sits in ampulla, and sends cilia from hair cells
  into gelatinous matrix (cupula) which moves
  opposite to direction of head movement due to
  surrounding viscous endolymph

10
Anatomy for Dummies

• Utricle Saccule
• detect linear acceleration changes in head
  position relative to gravity
• Maculae are the sensory organs w/in these
• Ca-carbonate crystals ( otoliths) in gelatinous
  matrix w/ embedded hair cells sense motion

11
Otoconia

• Otoconia debris in SCC either displaced
  otoliths (2o to trauma, infection etc) or clotted
  blood can cause abnormal endolymph flow and
  hence inappropriate stimulation of vestibular
  systems

12
Peripheral Vertigo

• SPINNED
• S Sudden onset / offset
• P Positional fatigable
• I Intense (more than central)
• N Nausea vomiting (more than central)
• N Normal neuro exam
• E Episodic (never lasts gt 2weeks)
• D no neuro deficits

13
Central vs. Peripheral

• Central
• Gradual onset
• Milder intensity
• Continuous for wks mos
• Min influenced by position
• Associated neuro findings
• Absence of auditory deficits
• Nystagmus
• Any direction
• Uni- or bilateral
• Not supressed by visual fixation (may enhance)
• Non-fatigable
• Mild intensity
• Sustained duration
• Short latency

• Peripheral
• Sudden onset
• Severe intensity
• Never lasts gt 2 weeks
• Positional
• Normal neuro exam
• May have auditory complaints e.g. tinnitus
• Nystagmus
• Horizontal or rotatory
• Never vertical
• Bilateral
• Supressed by visual fixation
• Transient (lasts secs mins)
• Episodic
• Mild severe intensity
• Fatigable
• Long latency

14
Vertigo DDx

• Peripheral
• FB in ear canal
• Cerumen impaction
• AOM
• BPV
• Labyrinthitis
• (suppurative, serous, toxic, chronic)
• Menieres Dz
• Vestibular neuronitis
• Acoustic neuroma

• Central
• Infection
• (meningitis, encephalitis, abscess)
• Vertebrobasilar insufficiency
• Cerebellar stroke
• Wallenbergs syndrome
• PICA occlusion
• Subcalvian steal
• Head or neck trauma
• Vertebrobasilar migraine
• Multiple sclerosis
• Temporal lobe epilepsy
• Tumor
• Hypoglycemia

15
What is the most difficult central cause to
detect?

• Cerebellar infarction
• Why? Scandinavian studies have shown that of
  older pts presenting with what appears to be
  peripheral vertigo 25 will actually have a
  cerebellar lesion
• Makes sorting out the older pt with acute vertigo
  imbalance more difficult
• CT will NOT help you -- if you want to r/o post
  fossa stroke you need a MRI

16
Cerebellar Stroke

• Account for 1.5 of all strokes
• Sudden onset severe vertigo, H/A, N V, ataxia
• May see ipsilateral CN VI deficit
• 2 common presentations are Anterior inferior
  cerebellar artery infarct posterior inferior
  cerebellar artery infarct
• The things that will kill you
• brainstem compression secondary to edema
• brainstem infarction
• hydrocephalus
• Tx
• Hydrocephalus may be amenable to surgical Tx
• Phenothiazines or odansetron for Sx control
• Antiplatelet Tx /- warfarin, CVS Dz RF
  modification
• Vestibular rehab once past acute phase
• Reasonable to start ASA in these pts arrange
  close f/u if otherwise well

17
AICA

• Ant inf Cerebellar a. infarct
• AICA supplies lateral cerebellum, dorsolateral
  pons, and labyrinth
• Sx depend on which of these are occluded
• Vertigo, N V, ataxia ant vestibular branch of
  labyrinth a.
• Hearing loss tinnitus common cochlear branch
  of labyrinth a.
• Dysarthria, ipsilateral facial palsy trigeminal
  sensory loss, Horners syndrome, dysmetria,
  contralateral pain temp loss pontine a.

18
Wallenbergs Syndrome

• PICA occlusion
• Infarcts post inf cerebellum dorsolateral
  medulla
• Sx
• Vertigo (vestibular nucleus in lateral medulla)
• N V
• Nystagmus that (if horizontal) may reverse
  direction on gaze toward affected side
• loss of pain temp sensation on ipsilateral face
  and contralateral body,
• Ataxia lateropulsion towards affected side
• hoarseness due to paralysis of palate, pharynx,
  and larynx
• Horners syndrome

19
Rosens Textbook of Emergency Medicine 2002
20
Pharmacological Management

• Diazepam
• 2-10 mg tid
• Anticholinergics
• Indicated for vestibular neuronitis (incl. RH
  Syndrome), labyrinthitis
• Meclizine (anti-vert) 25 mg q8h
• Diphenhydramine (benadryl) 25-50 mg q6-8h
• Promethazine (Phenergan)
• 25-50 mg PO/PR/IM q6-8h
• 12.5-25 mg IV
• Droperidol 2.5 mg IV
• Ondansetron
• Indicated for severe refractory N V from
  central causes
• 4 mg q8h x 3 d

21
Pharmacological Management

• Prednisone
• Indicated for Acute vestibular neuronits, RH
  Syndrome, severe N V from central causes
• 60 mg PO qd, then taper over 10d
• Acyclovir
• Indicated for Ramsay Hunt syndrome
• Important to start ASAP (ideally within 3 d of
  onset) to reduce facial nerve degeneration
  hearing loss)
• 400 mg 5x/d x10 d
• Antibiotics
• As indicated for Tx of OM in labyrinthitis

22
Non-Pharmacological Mgmt

• Vestibular Rehabilitation
• Not effective for central processes where
  nystagmus vertigo dont fatigue or habituate
• Will discuss more later

23
BPPVBenign Paroxysmal Positional Vertigo

• Short-lived (usually seconds)
• Positional
• often one triggering position or certain head
  positions w/ horizotorotary nystagmus that can be
  reproduced at bedside
• Fatigable
• Associated N V
• Most common cause of dizzy spells in elderly
  incidence increases with age
• Debris (otoconia) from utricle floats into post
  semicircular canal in supine position vertical
  head movements cause debris movement and
  stimulation of cupula causing Sx
• Often follows vestibular neuritis or minor head
  trauma

24
Dix-Hallpike Test
25
Roll Test

• For horizontal SCC BPPV
• Often wont see nystagmus w Hallpike
• Roll in plane of horizontal SCC
• A. start supine
• B. rapidly roll head to one side and look for
  nystagmus vertigo
• C. repeat other side affected side down will
  cause more nystagmus vertigo
• Can tell free-floating otoconia (canalithiasis)
  from otoconia fixed to cupula (cupulolithiasis)
  based on direction duration of nystagmus
• Canalithiasis geotropic fatigable
• Cupulolithiasis ageotropic sustained

26
BPPV

• Tx
• Vestibular suppressants short-term and prior to
  canalith repositioning maneuvers
• Canalith repositioning maneuvers (Epley or
  Semont)
• Said to be effective in 85-95 of pts w/ one
  treatment
• Pts can be taught to do this at home
• Continue until no further vertigo even w/ maneuver

27
Canalith Repositioning Maneuvers

• Side effects
• Neck pain 6
• Tx failure or displacing otoconia into another
  SCC 6
• Emesis 1
• Canalith jam
• Conversion of transient nystagmus to persistent
  nystagmus irrespective to head position (Tx w/
  vibrator or repeat maneuver)
• Contraindications
• Severe cervical spine disease
• Unstable cardiac disease
• High grade carotid stenosis

28
Canalith Repositioning Maneuver How effective
are they?

• Reports vary from 66-100 success in alleviating
  or decreasing Sx
• 30-50 will have recurrence requiring repeat Tx
• Problems
• no ED-based studies
• Small sample sizes
• Numerous outcome variables studied
• Highly selected populations
• Bottom-line
• Appear to be efficacious safe perhaps we are
  underutilizing them in the ED

29
Epley Maneuver

• Best for post SCC canalithiasis
• A. sitting upright turn head 45 deg towards
  affected side
• B. lie down into Dix-Hallpike position for min
  until Sx abate (20 sec 4)
• C. slowly turn head toward unaffected side
  keeping neck extended maintain for 20 secs
• D. Roll onto side with head turned 45 deg down
  towards floor. Maintain for 20 sec.
• E. Sit pt up slowly keeping head pitched down and
  deviated toward unaffected side
• Final instructions should be minimal had
  movements, no bending over, lying down, or head
  tilting for rest of day. F/U in 2 days -- 50
  will have recurrence

30
Semont Maneuver

• Best for post SCC cupulolithiasis
• 2nd choice for canaltithiasis
• Difficult in elderly b/c requires fast movements
• A. rotate head 45o to unaffected side maintain
  this head position throughout
• B. rapidly lie pt down sideways onto affected
  side wait 20 sec
• C. rapidly move pt through sitting position into
  affected side down wait 20 sec
• D. Move slowly into sitting position
• Repeat entire procedure again
• Same post-procedure care as Epleys

31
Brandt-Daroff TxVestibular Rehabilitation Therapy

• 3d line Tx for mild BPPV
• Can take up to 2 weeks to work
• A. turn head 45o to unaffected side
• B. lie down rapidly on affected side hold for
  20 sec or until vertigo stops
• C. sit up slowly, wait 20 sec
• D. turn head 45o to other side repeat procedure
  on other side
• Repeat 5 times in each direction 1-3x/d for until
  no vertigo for 2 consecutive days (up to 2 weeks)
• Works by moving otoconia back forth allowing it
  to move out of SCC break up dissolve

32
Bar-B-Q Tx

• For Tx of horizontal SCC BPPV
• A. lie supine w/ affected ear down
• B. Slowly roll head into supine position hold
  for 15 sec or until vertigo stops
• C. Roll head onto other side -- hold for 15 sec
  or until vertigo stops
• D. Roll head and body in same direction into
  prone position -- hold for 15 sec or until
  vertigo stops
• E. Roll head and body in same direction back into
  original starting position
• Slowly bring into sitting position
• For cupulolithiasis same procedure but more rapid
  head turning to try dislodge otoconia

33
Serous Labyrinthitis

• Mild severe positional Sx
• Usually follows ENT infection
• Acute severe vertigo, N V,a associated hearing
  loss of variable severity onset
• Minimal fever, not toxic
• Bacterial or viral etiology

34
Acute Suppurative Labyrinthitis

• Sx
• Coexisting acute exudative bacterial inner ear
  infection
• Severe N V hearing loss
• Febrile toxic pt
• Tx
• Admit for IV Abx /- surgical I D

35
Toxic Labyrinthitis

• Sx
• Gradually progressive Sx
• Secondary to ototoxic meds
• Can get hearing loss severe N V
• Gent more toxic to vestibular hair cells than
  cochlear function
• No positional nystagmus
• Tx
• Stop toxic drug
• ?steroids

36
Vestibular Neuronitis

• Presentation
• Peak incidence in 30s -50-s
• Acute severe vertigo Incs rapidly in intensity
  (hrs) subsides gradually (days)
• Can have mild persistent positional vertigo for
  wks mos
• Get N V, but NO auditory Sx Primary
  difference b/w neuronitis labyrinthitis is lack
  of tinnitus or hearing loss in neuronits
• Antecedent common cold in 50, or ototoxic
  exposure
• Likely reactivation of dormant HSV infection in
  Scarpas ganglia within vestibular nerve
• Ramsay Hunt Syndrome rare variant of vestibular
  neuronitis due to varicella zoster w/ CN VII
  VIII deficits.
• Tx with acyclovir prednisone
• Tx
• Prednisone for 10d may shorten course
• Vestibular rehab

37
Menieres Dz

• Presentation
• Recurrent sudden onset episodic severe rotational
  vertigo
• Last hrs - days
• Get long Sx-free remissions
• Associated N V, tinnitus, fluctuating hearing
  loss (low frequency senorineural)
• Felt to be due to decreased endolymph resorption
  in endolymphatic sac
• Tx
• Low Na diet (lt2 g/d), avoid caffeine EtOH,
  quit smoking
• Vasodilators, diuretics (acetazolamide 250 bid)
• Chemical ablation of vestibular function
  (streptomycin, gentamicin)
• Surgery

38
Acoustic Neuroma( vestibular schwannoma)

• Gradual onset increasing severity of
• Progressive or sudden unilateral sensorineural
  hearing loss
• Tinnitus
• Vertigo presenting Sx in up to 38 of pts
• Ataxia (truncal)
• Neuro findings (diminution or absence of corneal
  reflex CN VIII deficit
• Predisposed to females b/w 30-60 yo
• Dx
• look for speech discrimination deficits (light,
  right, might)
• MRI w/ gadolinium 100 sensitive CT unenhanced
  MRI will miss it!
• Tx
• Observation w/ serial imaging
• Surgical resection or XRT

39
Vertebrobasilar Insufficiency

• Get isolated vertigo lasting secs mins
• Often associated
• Headache
• Neuro Sx (dysarthria, ataxia, weakness, numbness,
  diplopia)
• TIAs
• Dx
• MRI, doppler U/S of carotids vertebrals
• Tx
• CVD risk factor modification, ASA, /- warfarin

40
Subclavian Steal Syndrome

• May present w/ syncopal episodes but usually w/
  more subtle Sx
• Arm fatigue cramps
• Lightheadedness
• Vertigo
• Decs or absent radial pulse on affected side
• Investigate w/ doppler U/S of carotid vertebral
  vessels /- angiogram

41
Head Neck Trauma

• Usually onset within 10 days of trauma
• May last wks mos
• Positional episodic lasting secs mins
• Usually self-limited
• Related to inner ear fistula or otoconia usually

42
Vertebrobasilar Migraine

• Typically begins in adolescence
• Multiple neuro Sx followed by headache
• Vertigo
• Dysarthria
• Ataxia
• Visual disturbances
• Paresthesias
• Complete resolution of neuro abnormalities after
  attack subsides

43
Multiple Sclerosis

• Onset usually in 20s-40s
• Bilateral internuclear opthalmoplegia virtually
  pathognomonic
• Vertigo develops in 30 at some point
• Associated ataxic eye movements
• N V

44
Temporal Lobe Epilepsy

• Spectrum of Sx
• Vertigo
• Memory impairments
• Hallucinations
• Trance-like state
• Blatant seizure activity
• aphasia

45
Vestibular Hypofunction

• Present w/ chronic unsteadiness and oscillopsia
  (illusion of motion in visual environment)
• 50 have associated hearing loss
• Usually bilateral loss of vestibular function
  most commonly idiopathic (degenerative), 30 due
  to ototoxicity (gent)
• Dont usually have vertigo b/c of bilateral
  nature of vestibular loss
• Tx
• Vestibular rehab

46
Meds that cause the Spins

• Vestibular Suppressants
• Meclizine
• Diazepam
• Short term use only as interfere with central
  compensation can lead to withdrawal effects
• Anti-convulsants
• Phenytoin, carbamezapine, barbiturates
• Anti-hypertensives
• HCTZ, lasix (ototoxic also), beta-blockers,
  alpha-blockers (prazosin, terosine), CCBs
• NSAIDs
• ASA is ototoxic

47
Meds that cause the Spins

• Antiarrythmics
• Amiodarone, quinine
• Anti-depressants
• amitryptiline, imipramine
• BDZs
• Muscle relaxants
• Cyclobenzaprine, orphenidriine, methocarbomol
• Antibiotics
• Streptomycin, gentamicin, tobramycin (ototoxicit)
• Chemotherapy agents
• Cisplatin (ototoxic)

48
Syncope
49
Definition

• Sudden temporary transient loss of
  consciousness and concurrent loss of postural
  tone with spontaneous recovery

50
The Trouble w/ Syncope

• Syncope is a Sx, not a disease
• gt 40 causes listed in Rosens
• By the time pt arrives theyre usually
  asymptomatic
• DDx ranges from benign causes to potentially
  fatal
• Lack of clear guidelines for investigations
• Difficult area to research given transient nature
  of Sx, and lack of gold standard diagnostic tool
  or work-up
• Precludes a one-size-fits-all approach

51
Syncope

• Occurs due to dysfunction of
• bilateral cerebral hemispheres
• or
• RAS in brainstem
• Reflects lack of
• adequate perfusion
• structural heart Dz, arrhythmias, loss of
  vascular tone
• or
• cellular dysfunction from
• direct injury
• cellular toxins

52
Syncope DDx

• Idiopathic 39 (13-42)
• Reflex-mediated
• vasovagal 14 (8-37)
• situational 3 (1-8)
• e.g. micturition
• Orthostatic hypotension 11 (4-13)
• Neurally mediated 7 (3-32)
• TIA, migraines, Szs

• Cardiac 18
• structural Dz 3 (1-8)
• arrhythmias 14 (4-26)
• Meds 3 (0-7)
• Psychiatric 1 (0-5)
• Other 5 (0-7)
• carotid sinus syncope
• hypoglycemia
• hyperventilation
• Schnipper Kapoor. Med Clin NA 2001

53
What you want to rule out

• Cardiac syncope
• 1 yr mortality 18-33
• compare with idiopathic syncope (6), non-CVS
  (0-12) and neurally-mediated (lt0.5)
• Catastrophic CNS events
• ischemia
• hemorrhage
• Miscellaneous rare but serious causes

54
Syncopal Hx

• what where you doing right before?
• did you have any warning signs or Sx?
• what did he/she do or look like while out?
• what was he/she like immediately after?
• PMHx previous episodes
• Family Hx
• sudden death, deafness, arrhythmias
• Meds

55
Yield of Tests in Syncope

• History Physical
• 45 (32-74)
• ECG
• 5 (1-11)
• Carotid sinus massage
• 46 (25-63)
• Psych evaluation
• 21 (20-24)
• CT head
• 4 (0-20)
• Labs
• 2-3 (CBC)
• Holter
• 19 (14-42)

• Echo
• 5-10
• Stress test
• 1
• EEG
• 1.5 (0-5)
• Electrophysiology studies
• 60 (18-75)
• External loop recorder
• 34 (24-36)
• Insertable loop recorder
• 59
• Tilt table test
• 49 (26-90)

Schnipper Kapoor. Med Clin NA. 2001
56
History Physical Exam

• Provides the diagnosis in almost half of all
  syncopal pts
• Full neuro exam mandatory think about doing a
  DRE to r/o GIB
• Yield of Hx and exam increases by another 8 with
  specific confirmatory testing
• Is the keystone to investiging all syncopal pts

57
ECG

• Not usually diagnostic per se (happens in less
  than 5) but often provides clues to underlying
  heart Dz
• E.g. conduction blocks, evidence of CAD or LVH
• Can guide further investigation
• Cheap, non-invasive, fast
• Should be done in most pts

58
Routine Labs

• Add very little diagnostic information unless
  specific suspicion
• e.g. hypoglycemia, hyponatremia, ARF
• Can be omitted from work-up if Hx exam fail to
  provide any clues to suspect lab abnormalities
• Pregnancy testing is helpful in select
  circumstances
• CBC if suspect anemia DRE

59
Stress Testing

• Utility primarily to rule in risk-stratify CAD
• Should be preceded by echo in pts with exertional
  syncope

60
Holter Monitor

• Useful if it shows an arrhythmia AND pt is
  symptomatic during the event
• Increased duration of monitoring yields small
  increases in sensitivity for non-diagnostic
  arrhythmias
• 24h 19 of pts have arrhythmia (only 4
  diagnostic
• 48h increases to 30 (none assd w/ Sx)
• 72h increases to 34 (none assd w/ Sx)
• Bass et al. Arch Int Med 150 1073-78. 1990

61
External Loop Recorder

• Similar to Holter w/ transtelephonic transmission
  
• Activated at Sx onset by pt
• postevent monitors record rhythm for preset
  time interval after activation
• pre-/postevent monitors records preset time
  intervals before and after event
• Used primarily in pts w/ frequent syncopal events
  who had negative Holters
• Limited if pt unable to activate monitor

62
Insertable Loop Recorder

• Same as external loop monitors but implanted like
  a pacemaker for 18 mo at a time
• Indications not clearly defined yet but have been
  used in pts w/ recurrent syncope NYD after
  standard investigations
• 27 yield for arrhythmia while symptomatic
• 32 yield for NSR while symptomatic

63
EEG

• Studies have shown that useful only if strong
  suspicion or evidence for a seizure

64
Head CT

• Overall yield 4 in syncopal pts
• all positive findings in pts with focal neuro
  findings or witnessed Szs
• Indicated for pts w/ syncope and
• focal neuro signs or Sx
• Seizure
• Head trauma

65
Carotid Sinus Massage

• Test for carotid sinus hypersensitivity
• suggested by Hx of syncope w/ head turning, tight
  collars, shaving etc
• positive test reproduction of Sx and
• asystole gt 3 sec (cardioinhibitory response)
• or
• 50 mm Hg drop in SBP (vasodepressor response)
• Pts w/ a positive test are candidates for
  consideration of a pacemaker
• Incidence of permanent neurologic sequelae is
  0.03, and transient deficits 0.1

66
Vasovagal Syncope

• Historical predictive features
• age lt55
• female
• obvious precipitating event
• antecedent diaphoresis
• antecedent palpitations
• post-event fatigue
• duration of recovery gt 1 min

67
Risk EstimationOsservatorio Epidemiologico sulla
Sincope nel Lazio Score

• OESIL Risk Score
• Age gt65
• PMHx of any cardiovascular dz
• Syncope without prodrome
• Abnormal ECG
• Score Mortality at 12 mo ()
• 0 0
• 1 0.8
• 2 19.6
• 3 34.7
• 4 57.1

Colivicchi et al Eur Heart J 24 811-19. 2003
68
Driving Syncope

• Canadian Guidelines
• private vehicles
• refrain from driving for 1 month after each
  syncopal episode if 1 or less episodes per yr
• refrain from driving for 3 months after each
  syncopal episode if gt 1 per yr
• commercial vehicles
• refrain from driving for 3 months after each
  syncopal episode if 1 or less episodes per yr
• refrain from driving for 12 months after each
  syncopal episode if gt 1 per yr

69
Diagnostic Algorithm
Rosens Textbook of Emergency Medicine 2002