Dizziness & VertigoDizziness & Vertigo

Moritz HaagerMoritz HaagerOct 16, 2003Oct 16, 2003

WADOWADO

111 yo female presents to the ED with the 111 yo female presents to the ED with the complaint of feeling “weak and dizzy all complaint of feeling “weak and dizzy all over”over”

How do you approach this?How do you approach this? What are some of the key questions you What are some of the key questions you

should ask?should ask?

ObjectivesObjectives Clearly define terminologyClearly define terminology

DizzinessDizziness VertigoVertigo Syncope & pre-syncopeSyncope & pre-syncope

Examine the differential diagnosis for eachExamine the differential diagnosis for each Look at what tests are usefulLook at what tests are useful Look at what drugs are useful & whenLook at what drugs are useful & when Develop an approach to the weak & dizzy Develop an approach to the weak & dizzy

ptpt

DizzinessDizziness Causes of Causes of

dizziness in a dizziness in a outpatient outpatient neurology clinic neurology clinic specializing in specializing in dizzinessdizziness

Dizziness is not a medical termDizziness is not a medical term Breaks down into 4 general categoriesBreaks down into 4 general categories

Vertigo Vertigo • e.g. BPPVe.g. BPPV

Syncope or pre-syncopeSyncope or pre-syncope• E.g. orthostatic hypotensionE.g. orthostatic hypotension

Dysequilibrium syndromeDysequilibrium syndrome Undifferentiated dizziness Undifferentiated dizziness

• PsychogenicPsychogenic E.g. anxietyE.g. anxiety

• Systemic illnesses w/ malaiseSystemic illnesses w/ malaise E.g. pyleonephritis, hypoglycemiaE.g. pyleonephritis, hypoglycemia

• Who-kows-whats-the-&#@# -is-going-on-hereWho-kows-whats-the-&#@# -is-going-on-here

The Dizzy HistoryThe Dizzy History What do you mean by dizzy?What do you mean by dizzy?

Vertigo vs. pre-syncope/syncope vs. weakness/malaiseVertigo vs. pre-syncope/syncope vs. weakness/malaise What precipitates it?What precipitates it? How fast does it come on? How long does it last?How fast does it come on? How long does it last? Are there any associated hearing changes?Are there any associated hearing changes? Is there any evidence of other neurologic Is there any evidence of other neurologic

abnormalities?abnormalities? What meds are you on, or have you been on What meds are you on, or have you been on

recently?recently? Any head trauma?Any head trauma?

Dysequilibrium SyndromeDysequilibrium Syndrome

Age-related degeneration of visual, Age-related degeneration of visual, proprioceptive, and vestibular systemsproprioceptive, and vestibular systems

Pts have great difficulty with getting about Pts have great difficulty with getting about especially at night with diminished lightespecially at night with diminished light

Present to ED with hip fracturesPresent to ED with hip fractures

VertigoVertigo

DefinitionDefinition The illusion or sensation of movement of the The illusion or sensation of movement of the

pt or the pts surroundings (aka “the spins” in pt or the pts surroundings (aka “the spins” in EtOH intoxication)EtOH intoxication)

Usually 2Usually 2oo to pathological basis, but need to to pathological basis, but need to differentiate benign from sinisterdifferentiate benign from sinister

Start by differentiating peripheral vertigo from Start by differentiating peripheral vertigo from centralcentral

Anatomy for DummiesAnatomy for Dummies Semi-circular canalsSemi-circular canals

3 semi-circular canals at 3 semi-circular canals at right angles to each other right angles to each other to detect angular to detect angular accelerationacceleration

• Crista ampullaris = Crista ampullaris = sensory organsensory organ

• Sits in ampulla, and sends Sits in ampulla, and sends cilia from hair cells into cilia from hair cells into gelatinous matrix (cupula) gelatinous matrix (cupula) which moves opposite to which moves opposite to direction of head direction of head movement due to movement due to surrounding viscous surrounding viscous endolymphendolymph

Anatomy for DummiesAnatomy for Dummies Utricle & Saccule Utricle & Saccule

detect linear detect linear acceleration & acceleration & changes in head changes in head position relative to position relative to gravitygravity

• Maculae are the Maculae are the sensory organs w/in sensory organs w/in thesethese

• Ca-carbonate crystals Ca-carbonate crystals (= otoliths) in gelatinous (= otoliths) in gelatinous matrix w/ embedded matrix w/ embedded hair cells sense motionhair cells sense motion

OtoconiaOtoconia

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

Peripheral VertigoPeripheral Vertigo

SPINNEDSPINNED S – S – SSudden onset / offsetudden onset / offset P – P – PPositional & fatigableositional & fatigable I – I – IIntense (more than central)ntense (more than central) N – N – NNausea & vomiting (more than central)ausea & vomiting (more than central) N – Normal N – Normal nneuro exam euro exam E – E – EEpisodic (never lasts > 2weeks)pisodic (never lasts > 2weeks) D – no neuro D – no neuro ddeficitseficits

Central vs. PeripheralCentral vs. Peripheral CentralCentral

Gradual onsetGradual onset Milder intensityMilder intensity Continuous for wks – mosContinuous for wks – mos Min influenced by positionMin influenced by position Associated neuro findingsAssociated neuro findings Absence of auditory deficits Absence of auditory deficits NystagmusNystagmus

• Any directionAny direction• Uni- or bilateralUni- or bilateral• Not supressed by visual Not supressed by visual

fixation (may enhance)fixation (may enhance)• Non-fatigableNon-fatigable• Mild intensityMild intensity• Sustained durationSustained duration• Short latencyShort latency

PeripheralPeripheral Sudden onsetSudden onset Severe intensitySevere intensity Never lasts > 2 weeksNever lasts > 2 weeks PositionalPositional Normal neuro examNormal neuro exam May have auditory complaints May have auditory complaints

e.g. tinnituse.g. tinnitus NystagmusNystagmus

• Horizontal or rotatoryHorizontal or rotatory• Never verticalNever vertical• BilateralBilateral• Supressed by visual fixationSupressed by visual fixation• Transient (lasts sec’s – mins)Transient (lasts sec’s – mins)• EpisodicEpisodic• Mild – severe intensityMild – severe intensity• FatigableFatigable• Long latencyLong latency

Vertigo DDxVertigo DDx PeripheralPeripheral

FB in ear canalFB in ear canal Cerumen impactionCerumen impaction AOMAOM BPVBPV LabyrinthitisLabyrinthitis

• (suppurative, serous, (suppurative, serous, toxic, chronic)toxic, chronic)

Meniere’s Dz: Meniere’s Dz: Vestibular neuronitisVestibular neuronitis Acoustic neuromaAcoustic neuroma

CentralCentral InfectionInfection

• (meningitis, encephalitis, (meningitis, encephalitis, abscess)abscess)

Vertebrobasilar insufficiencyVertebrobasilar insufficiency Cerebellar strokeCerebellar stroke Wallenberg’s syndromeWallenberg’s syndrome

• PICA occlusionPICA occlusion Subcalvian stealSubcalvian steal Head or neck traumaHead or neck trauma Vertebrobasilar migraineVertebrobasilar migraine Multiple sclerosisMultiple sclerosis Temporal lobe epilepsyTemporal lobe epilepsy TumorTumor HypoglycemiaHypoglycemia

What is the most difficult central What is the most difficult central cause to detect?cause to detect?

Cerebellar infarctionCerebellar infarction Why? Scandinavian studies have shown that Why? Scandinavian studies have shown that

of older pts presenting with what appears to of older pts presenting with what appears to be peripheral vertigo 25% will actually have a be peripheral vertigo 25% will actually have a cerebellar lesioncerebellar lesion

Makes sorting out the older pt with acute Makes sorting out the older pt with acute vertigo & imbalance more difficultvertigo & imbalance more difficult

CT will NOT help you -- if you want to r/o post CT will NOT help you -- if you want to r/o post fossa stroke you need a MRIfossa stroke you need a MRI

Cerebellar StrokeCerebellar Stroke Account for ~1.5% of all strokesAccount for ~1.5% of all strokes Sudden onset severe vertigo, H/A, N & V, ataxiaSudden onset severe vertigo, H/A, N & V, ataxia May see ipsilateral CN VI deficitMay see ipsilateral CN VI deficit 2 common presentations are Anterior inferior cerebellar artery 2 common presentations are Anterior inferior cerebellar artery

infarct & posterior inferior cerebellar artery infarctinfarct & posterior inferior cerebellar artery infarct The things that will kill you:The things that will kill you:

brainstem compression secondary to edemabrainstem compression secondary to edema brainstem infarctionbrainstem infarction hydrocephalushydrocephalus

TxTx Hydrocephalus may be amenable to surgical TxHydrocephalus may be amenable to surgical Tx Phenothiazines or odansetron for Sx control;Phenothiazines or odansetron for Sx control; Antiplatelet Tx +/- warfarin, CVS Dz RF modificationAntiplatelet Tx +/- warfarin, CVS Dz RF modification Vestibular rehab once past acute phaseVestibular rehab once past acute phase Reasonable to start ASA in these pts & arrange close f/u if otherwise wellReasonable to start ASA in these pts & arrange close f/u if otherwise well

AICAAICA Ant inf Cerebellar a. infarct:Ant inf Cerebellar a. infarct:

AICA supplies lateral cerebellum, dorsolateral AICA supplies lateral cerebellum, dorsolateral pons, and labyrinthpons, and labyrinth

Sx depend on which of these are occludedSx depend on which of these are occluded• Vertigo, N & V, ataxia = ant vestibular branch of Vertigo, N & V, ataxia = ant vestibular branch of

labyrinth a.labyrinth a.• Hearing loss & tinnitus = common cochlear branch Hearing loss & tinnitus = common cochlear branch

of labyrinth a.of labyrinth a.• Dysarthria, ipsilateral facial palsy & trigeminal Dysarthria, ipsilateral facial palsy & trigeminal

sensory loss, Horner’s syndrome, dysmetria, sensory loss, Horner’s syndrome, dysmetria, contralateral pain & temp loss = pontine a.contralateral pain & temp loss = pontine a.

Wallenberg’s SyndromeWallenberg’s Syndrome PICA occlusion PICA occlusion

Infarcts post inf cerebellum & dorsolateral medullaInfarcts post inf cerebellum & dorsolateral medulla Sx:Sx:

• Vertigo (vestibular nucleus in lateral medulla)Vertigo (vestibular nucleus in lateral medulla)• N & VN & V• Nystagmus that (if horizontal) may reverse direction on gaze Nystagmus that (if horizontal) may reverse direction on gaze

toward affected sidetoward affected side• loss of pain & temp sensation on ipsilateral face and loss of pain & temp sensation on ipsilateral face and

contralateral body, contralateral body, • Ataxia & lateropulsion towards affected sideAtaxia & lateropulsion towards affected side• hoarseness due to paralysis of palate, pharynx, and larynxhoarseness due to paralysis of palate, pharynx, and larynx• Horners syndromeHorners syndrome

Rosen’s Textbook of Emergency Medicine 2002

Pharmacological ManagementPharmacological Management DiazepamDiazepam

2-10 mg tid2-10 mg tid AnticholinergicsAnticholinergics

Indicated for vestibular neuronitis (incl. RH Syndrome), & labyrinthitisIndicated for vestibular neuronitis (incl. RH Syndrome), & labyrinthitis Meclizine (anti-vert) 25 mg q8hMeclizine (anti-vert) 25 mg q8h Diphenhydramine (benadryl) 25-50 mg q6-8hDiphenhydramine (benadryl) 25-50 mg q6-8h Promethazine (Phenergan) Promethazine (Phenergan)

• 25-50 mg PO/PR/IM q6-8h25-50 mg PO/PR/IM q6-8h• 12.5-25 mg IV12.5-25 mg IV

Droperidol 2.5 mg IVDroperidol 2.5 mg IV OndansetronOndansetron

Indicated for severe refractory N & V from central causesIndicated for severe refractory N & V from central causes 4 mg q8h x 3 d4 mg q8h x 3 d

Pharmacological ManagementPharmacological Management PrednisonePrednisone

Indicated for Acute vestibular neuronits, RH Indicated for Acute vestibular neuronits, RH Syndrome, & severe N & V from central causesSyndrome, & severe N & V from central causes

60 mg PO qd, then taper over 10d60 mg PO qd, then taper over 10d AcyclovirAcyclovir

Indicated for Ramsay Hunt syndromeIndicated for Ramsay Hunt syndrome Important to start ASAP (ideally within 3 d of onset) to Important to start ASAP (ideally within 3 d of onset) to

reduce facial nerve degeneration & hearing loss)reduce facial nerve degeneration & hearing loss) 400 mg 5x/d x10 d400 mg 5x/d x10 d

AntibioticsAntibiotics As indicated for Tx of OM in labyrinthitisAs indicated for Tx of OM in labyrinthitis

Non-Pharmacological MgmtNon-Pharmacological Mgmt

Vestibular RehabilitationVestibular Rehabilitation Not effective for central processes where Not effective for central processes where

nystagmus & vertigo don’t fatigue or habituatenystagmus & vertigo don’t fatigue or habituate Will discuss more laterWill discuss more later

BPPVBPPVBenign Paroxysmal Positional VertigoBenign Paroxysmal Positional Vertigo

Short-lived (usually seconds)Short-lived (usually seconds) PositionalPositional

often one triggering position or certain head positions w/ often one triggering position or certain head positions w/ horizotorotary nystagmus that can be reproduced at bedsidehorizotorotary nystagmus that can be reproduced at bedside

FatigableFatigable Associated N & VAssociated N & V Most common cause of “dizzy spells” in elderly; incidence Most common cause of “dizzy spells” in elderly; incidence

increases with age increases with age Debris (otoconia) from utricle floats into post semicircular Debris (otoconia) from utricle floats into post semicircular

canal in supine position – vertical head movements cause canal in supine position – vertical head movements cause debris movement and stimulation of cupula causing Sxdebris movement and stimulation of cupula causing Sx

Often follows vestibular neuritis or minor head traumaOften follows vestibular neuritis or minor head trauma

Dix-Hallpike TestDix-Hallpike Test

Roll TestRoll Test For horizontal SCC BPPVFor horizontal SCC BPPV Often won’t see nystagmus w Often won’t see nystagmus w

HallpikeHallpike Roll in plane of horizontal SCCRoll in plane of horizontal SCC

A. start supineA. start supine B. rapidly roll head to one side B. rapidly roll head to one side

and look for nystagmus & vertigoand look for nystagmus & vertigo C. repeat other side – affected C. repeat other side – affected

side down will cause more side down will cause more nystagmus & vertigonystagmus & vertigo

Can tell free-floating otoconia Can tell free-floating otoconia (canalithiasis) from otoconia fixed (canalithiasis) from otoconia fixed to cupula (cupulolithiasis) based to cupula (cupulolithiasis) based on direction & duration of on direction & duration of nystagmusnystagmus

Canalithiasis – geotropic & Canalithiasis – geotropic & fatigablefatigable

Cupulolithiasis – ageotropic & Cupulolithiasis – ageotropic & sustainedsustained

BPPVBPPV

TxTx Vestibular suppressants short-term and prior Vestibular suppressants short-term and prior

to canalith repositioning maneuversto canalith repositioning maneuvers Canalith repositioning maneuvers (Epley or Canalith repositioning maneuvers (Epley or

Semont)Semont)• Said to be effective in 85-95% of pts w/ one Said to be effective in 85-95% of pts w/ one

treatmenttreatment• Pts can be taught to do this at homePts can be taught to do this at home• Continue until no further vertigo even w/ maneuverContinue until no further vertigo even w/ maneuver

Canalith Repositioning ManeuversCanalith Repositioning Maneuvers Side effectsSide effects

Neck pain ~6%Neck pain ~6% Tx failure or displacing otoconia into another SCC Tx failure or displacing otoconia into another SCC

~6%~6% Emesis ~1%Emesis ~1% Canalith jamCanalith jam

• Conversion of transient nystagmus to persistent nystagmus Conversion of transient nystagmus to persistent nystagmus irrespective to head position (Tx w/ vibrator or repeat irrespective to head position (Tx w/ vibrator or repeat maneuver)maneuver)

ContraindicationsContraindications Severe cervical spine diseaseSevere cervical spine disease Unstable cardiac diseaseUnstable cardiac disease High grade carotid stenosisHigh grade carotid stenosis

Canalith Repositioning Maneuver: Canalith Repositioning Maneuver: How effective are they?How effective are they?

Reports vary from 66-100% success in Reports vary from 66-100% success in alleviating or decreasing Sxalleviating or decreasing Sx

30-50% will have recurrence requiring repeat Tx30-50% will have recurrence requiring repeat Tx Problems Problems

no ED-based studiesno ED-based studies Small sample sizesSmall sample sizes Numerous outcome variables studiedNumerous outcome variables studied Highly selected populationsHighly selected populations

Bottom-line:Bottom-line: Appear to be efficacious & safe – perhaps we are Appear to be efficacious & safe – perhaps we are

underutilizing them in the EDunderutilizing them in the ED

Epley ManeuverEpley Maneuver Best for post SCC canalithiasisBest for post SCC canalithiasis

A. sitting upright turn head 45 deg A. sitting upright turn head 45 deg towards affected sidetowards affected side

B. lie down into Dix-Hallpike B. lie down into Dix-Hallpike position for min until Sx abate (20 position for min until Sx abate (20 sec – 4) sec – 4)

C. slowly turn head toward C. slowly turn head toward unaffected side keeping neck unaffected side keeping neck extended & maintain for 20 secsextended & maintain for 20 secs

D. Roll onto side with head turned D. Roll onto side with head turned 45 deg down towards floor. 45 deg down towards floor. Maintain for 20 sec.Maintain for 20 sec.

E. Sit pt up slowly keeping head E. Sit pt up slowly keeping head pitched down and deviated toward pitched down and deviated toward unaffected sideunaffected side

Final instructions should be Final instructions should be minimal had movements, no minimal had movements, no bending over, lying down, or head bending over, lying down, or head tilting for rest of day. F/U in 2 tilting for rest of day. F/U in 2 days -- 50% will have recurrencedays -- 50% will have recurrence

Semont ManeuverSemont Maneuver Best for post SCC cupulolithiasisBest for post SCC cupulolithiasis 22ndnd choice for canaltithiasis choice for canaltithiasis Difficult in elderly b/c requires fast Difficult in elderly b/c requires fast

movementsmovements A. rotate head 45A. rotate head 45oo to unaffected to unaffected

side; maintain this head position side; maintain this head position throughoutthroughout

B. rapidly lie pt down sideways B. rapidly lie pt down sideways onto affected side – wait 20 seconto affected side – wait 20 sec

C. rapidly move pt through sitting C. rapidly move pt through sitting position into affected side down – position into affected side down – wait 20 secwait 20 sec

D. Move slowly into sitting positionD. Move slowly into sitting position Repeat entire procedure againRepeat entire procedure again Same post-procedure care as Same post-procedure care as

Epley’sEpley’s

Brandt-Daroff TxBrandt-Daroff TxVestibular Rehabilitation TherapyVestibular Rehabilitation Therapy

3d line Tx for mild BPPV3d line Tx for mild BPPV Can take up to 2 weeks to workCan take up to 2 weeks to work

A. turn head 45A. turn head 45oo to unaffected side to unaffected side B. lie down rapidly on affected B. lie down rapidly on affected

side – hold for 20 sec or until side – hold for 20 sec or until vertigo stopsvertigo stops

C. sit up slowly, wait 20 secC. sit up slowly, wait 20 sec D. turn head 45D. turn head 45oo to other side & to other side &

repeat procedure on other siderepeat procedure on other side Repeat 5 times in each direction Repeat 5 times in each direction

1-3x/d for until no vertigo for 2 1-3x/d for until no vertigo for 2 consecutive days (up to 2 weeks)consecutive days (up to 2 weeks)

Works by moving otoconia back & Works by moving otoconia back & forth allowing it to move out of forth allowing it to move out of SCC & break up & dissolveSCC & break up & dissolve

Bar-B-Q TxBar-B-Q Tx For Tx of horizontal SCC BPPVFor Tx of horizontal SCC BPPV

A. lie supine w/ affected ear downA. lie supine w/ affected ear down B. Slowly roll head into supine B. Slowly roll head into supine

position – hold for 15 sec or until position – hold for 15 sec or until vertigo stopsvertigo stops

C. Roll head onto other side -- C. Roll head onto other side -- hold for 15 sec or until vertigo hold for 15 sec or until vertigo stopsstops

D. Roll head and body in same D. Roll head and body in same direction into prone position -- hold direction into prone position -- hold for 15 sec or until vertigo stopsfor 15 sec or until vertigo stops

E. Roll head and body in same E. Roll head and body in same direction back into original starting direction back into original starting positionposition

Slowly bring into sitting positionSlowly bring into sitting position For cupulolithiasis same For cupulolithiasis same

procedure but more rapid head procedure but more rapid head turning to try & dislodge otoconiaturning to try & dislodge otoconia

Serous LabyrinthitisSerous Labyrinthitis

Mild – severe positional SxMild – severe positional Sx Usually follows ENT infectionUsually follows ENT infection Acute severe vertigo, N & V,a associated Acute severe vertigo, N & V,a associated

hearing loss of variable severity & onsethearing loss of variable severity & onset Minimal fever, not toxicMinimal fever, not toxic Bacterial or viral etiologyBacterial or viral etiology

Acute Suppurative LabyrinthitisAcute Suppurative Labyrinthitis

SxSx Coexisting acute exudative bacterial inner ear Coexisting acute exudative bacterial inner ear

infectioninfection Severe N & V & hearing lossSevere N & V & hearing loss Febrile toxic ptFebrile toxic pt

TxTx Admit for IV Abx +/- surgical I & DAdmit for IV Abx +/- surgical I & D

Toxic LabyrinthitisToxic Labyrinthitis SxSx

Gradually progressive SxGradually progressive Sx Secondary to ototoxic medsSecondary to ototoxic meds Can get hearing loss & severe N & V Can get hearing loss & severe N & V

• Gent more toxic to vestibular hair cells than cochlear functionGent more toxic to vestibular hair cells than cochlear function No positional nystagmusNo positional nystagmus

TxTx Stop toxic drugStop toxic drug ?steroids?steroids

Vestibular NeuronitisVestibular Neuronitis PresentationPresentation

Peak incidence in 30’s -50-s Peak incidence in 30’s -50-s Acute severe vertigo; Inc’s rapidly in intensity (hrs) & subsides Acute severe vertigo; Inc’s rapidly in intensity (hrs) & subsides

gradually (days) gradually (days) Can have mild persistent positional vertigo for wks – mosCan have mild persistent positional vertigo for wks – mos Get N & V, but Get N & V, but NO auditory Sx : NO auditory Sx : Primary difference b/w neuronitis & Primary difference b/w neuronitis &

labyrinthitis is lack of tinnitus or hearing loss in neuronitslabyrinthitis is lack of tinnitus or hearing loss in neuronits Antecedent common cold in ~50%, or ototoxic exposureAntecedent common cold in ~50%, or ototoxic exposure Likely reactivation of dormant HSV infection in Scarpas ganglia Likely reactivation of dormant HSV infection in Scarpas ganglia

within vestibular nervewithin vestibular nerve Ramsay Hunt Syndrome = rare variant of vestibular Ramsay Hunt Syndrome = rare variant of vestibular

neuronitis due to varicella zoster w/ CN VII & VIII deficits.neuronitis due to varicella zoster w/ CN VII & VIII deficits. Tx with acyclovir & prednisoneTx with acyclovir & prednisone

TxTx Prednisone for 10d may shorten coursePrednisone for 10d may shorten course Vestibular rehabVestibular rehab

Meniere’s DzMeniere’s Dz PresentationPresentation

Recurrent sudden onset episodic severe rotational vertigoRecurrent sudden onset episodic severe rotational vertigo Last hrs - daysLast hrs - days Get long Sx-free remissionsGet long Sx-free remissions Associated N & V, tinnitus, & fluctuating hearing loss (low Associated N & V, tinnitus, & fluctuating hearing loss (low

frequency senorineural)frequency senorineural) Felt to be due to decreased endolymph resorption in Felt to be due to decreased endolymph resorption in

endolymphatic sacendolymphatic sac TxTx

Low Na diet (<2 g/d), avoid caffeine & EtOH, quit smokingLow Na diet (<2 g/d), avoid caffeine & EtOH, quit smoking Vasodilators, diuretics (acetazolamide 250 bid)Vasodilators, diuretics (acetazolamide 250 bid) Chemical ablation of vestibular function (streptomycin, Chemical ablation of vestibular function (streptomycin,

gentamicin)gentamicin) SurgerySurgery

Acoustic NeuromaAcoustic Neuroma(= vestibular schwannoma)(= vestibular schwannoma)

Gradual onset & increasing severity of:Gradual onset & increasing severity of: Progressive or sudden unilateral sensorineural hearing loss Progressive or sudden unilateral sensorineural hearing loss TinnitusTinnitus Vertigo = presenting Sx in up to 38% of ptsVertigo = presenting Sx in up to 38% of pts Ataxia (truncal)Ataxia (truncal) Neuro findings (diminution or absence of corneal reflex; CN VIII Neuro findings (diminution or absence of corneal reflex; CN VIII

deficitdeficit Predisposed to females b/w 30-60 yoPredisposed to females b/w 30-60 yo DxDx

look for speech discrimination deficits (light, right, might)look for speech discrimination deficits (light, right, might) MRI w/ gadolinium 100% sensitive; CT & unenhanced MRI will miss MRI w/ gadolinium 100% sensitive; CT & unenhanced MRI will miss

it!it! TxTx

Observation w/ serial imagingObservation w/ serial imaging Surgical resection or XRTSurgical resection or XRT

Vertebrobasilar InsufficiencyVertebrobasilar Insufficiency Get isolated vertigo lasting secs – minsGet isolated vertigo lasting secs – mins Often associated:Often associated:

HeadacheHeadache Neuro Sx (dysarthria, ataxia, weakness, numbness, Neuro Sx (dysarthria, ataxia, weakness, numbness,

diplopia) diplopia) TIA’sTIA’s

DxDx MRI, doppler U/S of carotids & vertebralsMRI, doppler U/S of carotids & vertebrals

TxTx CVD risk factor modification, ASA, +/- warfarinCVD risk factor modification, ASA, +/- warfarin

Subclavian Steal SyndromeSubclavian Steal Syndrome

May present w/ syncopal episodes but May present w/ syncopal episodes but usually w/ more subtle Sx:usually w/ more subtle Sx: Arm fatigue & crampsArm fatigue & cramps LightheadednessLightheadedness VertigoVertigo Dec’s or absent radial pulse on affected sideDec’s or absent radial pulse on affected side Investigate w/ doppler U/S of carotid & Investigate w/ doppler U/S of carotid &

vertebral vessels +/- angiogramvertebral vessels +/- angiogram

Head & Neck TraumaHead & Neck Trauma

Usually onset within 10 days of traumaUsually onset within 10 days of trauma May last wks – mosMay last wks – mos Positional & episodic lasting secs – minsPositional & episodic lasting secs – mins Usually self-limitedUsually self-limited Related to inner ear fistula or otoconia Related to inner ear fistula or otoconia

usuallyusually

Vertebrobasilar MigraineVertebrobasilar Migraine

Typically begins in adolescence:Typically begins in adolescence: Multiple neuro Sx followed by headache:Multiple neuro Sx followed by headache:

• Vertigo Vertigo • DysarthriaDysarthria• AtaxiaAtaxia• Visual disturbancesVisual disturbances• ParesthesiasParesthesias

Complete resolution of neuro abnormalities Complete resolution of neuro abnormalities after attack subsidesafter attack subsides

Multiple SclerosisMultiple Sclerosis

Onset usually in 20’s-40’sOnset usually in 20’s-40’s Bilateral internuclear opthalmoplegia Bilateral internuclear opthalmoplegia

virtually pathognomonicvirtually pathognomonic Vertigo develops in ~30% at some pointVertigo develops in ~30% at some point

Associated ataxic eye movementsAssociated ataxic eye movements N & VN & V

Temporal Lobe EpilepsyTemporal Lobe Epilepsy

Spectrum of Sx:Spectrum of Sx: VertigoVertigo Memory impairmentsMemory impairments HallucinationsHallucinations Trance-like stateTrance-like state Blatant seizure activityBlatant seizure activity aphasiaaphasia

Vestibular HypofunctionVestibular Hypofunction Present w/ chronic unsteadiness and oscillopsia Present w/ chronic unsteadiness and oscillopsia

(illusion of motion in visual environment)(illusion of motion in visual environment) ~50% have associated hearing loss~50% have associated hearing loss Usually Usually bilateralbilateral loss of vestibular function most loss of vestibular function most

commonly idiopathic (degenerative), ~30% due commonly idiopathic (degenerative), ~30% due to ototoxicity (gent)to ototoxicity (gent)

Don’t usually have vertigo b/c of bilateral nature Don’t usually have vertigo b/c of bilateral nature of vestibular lossof vestibular loss

TxTx Vestibular rehabVestibular rehab

Meds that cause the SpinsMeds that cause the Spins Vestibular SuppressantsVestibular Suppressants

MeclizineMeclizine DiazepamDiazepam

• Short term use only as interfere with central compensation & Short term use only as interfere with central compensation & can lead to withdrawal effectscan lead to withdrawal effects

Anti-convulsantsAnti-convulsants Phenytoin, carbamezapine, barbituratesPhenytoin, carbamezapine, barbiturates

Anti-hypertensivesAnti-hypertensives• HCTZ, lasix (ototoxic also), beta-blockers, alpha-blockers HCTZ, lasix (ototoxic also), beta-blockers, alpha-blockers

(prazosin, terosine), CCB’s(prazosin, terosine), CCB’s NSAIDsNSAIDs

ASA is ototoxicASA is ototoxic

Meds that cause the SpinsMeds that cause the Spins AntiarrythmicsAntiarrythmics

Amiodarone, quinineAmiodarone, quinine Anti-depressantsAnti-depressants

amitryptiline, imipramineamitryptiline, imipramine BDZ’sBDZ’s Muscle relaxantsMuscle relaxants

Cyclobenzaprine, orphenidriine, methocarbomolCyclobenzaprine, orphenidriine, methocarbomol AntibioticsAntibiotics

Streptomycin, gentamicin, tobramycin (ototoxicit)Streptomycin, gentamicin, tobramycin (ototoxicit) Chemotherapy agentsChemotherapy agents

Cisplatin (ototoxic)Cisplatin (ototoxic)

SyncopeSyncope

DefinitionDefinition

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

The Trouble w/ SyncopeThe Trouble w/ Syncope Syncope is a Sx, not a diseaseSyncope is a Sx, not a disease

> 40 causes listed in Rosen’s> 40 causes listed in Rosen’s By the time pt arrives they’re usually asymptomaticBy the time pt arrives they’re usually asymptomatic DDx ranges from benign causes to potentially fatalDDx ranges from benign causes to potentially fatal

Lack of clear guidelines for investigationsLack of clear guidelines for investigations Difficult area to research given transient nature of Sx, Difficult area to research given transient nature of Sx,

and lack of gold standard diagnostic tool or work-upand lack of gold standard diagnostic tool or work-up

Precludes a one-size-fits-all approachPrecludes a one-size-fits-all approach

SyncopeSyncope Occurs due to dysfunction of:Occurs due to dysfunction of:

bilateral cerebral hemispheresbilateral cerebral hemispheresoror RAS in brainstemRAS in brainstem

Reflects lack of Reflects lack of adequate perfusionadequate perfusion

• structural heart Dz, arrhythmias, loss of vascular tonestructural heart Dz, arrhythmias, loss of vascular tone

oror cellular dysfunction from cellular dysfunction from

• direct injury direct injury • cellular toxinscellular toxins

Syncope DDxSyncope DDx Idiopathic 39% (13-42)Idiopathic 39% (13-42) Reflex-mediatedReflex-mediated

vasovagal 14% (8-37)vasovagal 14% (8-37) situational 3% (1-8)situational 3% (1-8)

• e.g. micturitione.g. micturition Orthostatic hypotension Orthostatic hypotension

11% (4-13)11% (4-13) Neurally mediated 7% (3-Neurally mediated 7% (3-

32)32) TIA, migraines, Sz’sTIA, migraines, Sz’s

Cardiac 18%Cardiac 18% structural Dz 3% (1-8)structural Dz 3% (1-8) arrhythmias 14% (4-26)arrhythmias 14% (4-26)

MedsMeds 3% (0-7)3% (0-7) Psychiatric 1% (0-5)Psychiatric 1% (0-5) Other 5% (0-7)Other 5% (0-7)

carotid sinus syncopecarotid sinus syncope hypoglycemiahypoglycemia hyperventilation hyperventilation

Schnipper & Kapoor. Med Clin NA Schnipper & Kapoor. Med Clin NA 20012001

What you want to rule outWhat you want to rule out

Cardiac syncopeCardiac syncope 1 yr mortality 18-33%1 yr mortality 18-33% compare with idiopathic syncope (6%), non-compare with idiopathic syncope (6%), non-

CVS (0-12%) and neurally-mediated (<0.5%)CVS (0-12%) and neurally-mediated (<0.5%) Catastrophic CNS eventsCatastrophic CNS events

ischemiaischemia hemorrhagehemorrhage

Miscellaneous rare but serious causesMiscellaneous rare but serious causes

Syncopal HxSyncopal Hx what where you doing right before?what where you doing right before? did you have any warning signs or Sx?did you have any warning signs or Sx? what did he/she do or look like while out?what did he/she do or look like while out? what was he/she like immediately after?what was he/she like immediately after? PMHx & previous episodesPMHx & previous episodes Family HxFamily Hx

sudden death, deafness, arrhythmiassudden death, deafness, arrhythmias MedsMeds

Yield of Tests in SyncopeYield of Tests in Syncope History & PhysicalHistory & Physical

45% (32-74)45% (32-74) ECGECG

5% (1-11)5% (1-11) Carotid sinus massageCarotid sinus massage

46% (25-63)46% (25-63) Psych evaluationPsych evaluation

21% (20-24)21% (20-24) CT headCT head

4% (0-20)4% (0-20) LabsLabs

2-3% 2-3% (CBC) (CBC) HolterHolter

19% (14-42)19% (14-42)

EchoEcho 5-10%5-10%

Stress testStress test 1%1%

EEGEEG 1.5% (0-5)1.5% (0-5)

Electrophysiology studiesElectrophysiology studies 60% (18-75)60% (18-75)

External loop recorderExternal loop recorder 34% (24-36)34% (24-36)

Insertable loop recorderInsertable loop recorder 59%59%

Tilt table testTilt table test 49% (26-90)49% (26-90)

Schnipper & Kapoor. Med Clin NA. 2001Schnipper & Kapoor. Med Clin NA. 2001

History & Physical ExamHistory & Physical Exam Provides the diagnosis in almost half of all Provides the diagnosis in almost half of all

syncopal ptssyncopal pts Full neuro exam mandatory; think about Full neuro exam mandatory; think about

doing a DRE to r/o GIBdoing a DRE to r/o GIB Yield of Hx and exam increases by another Yield of Hx and exam increases by another

8% with specific confirmatory testing8% with specific confirmatory testing Is the keystone to investiging all syncopal Is the keystone to investiging all syncopal

ptspts

ECGECG

Not usually diagnostic per se (happens in Not usually diagnostic per se (happens in less than 5%) but often provides clues to less than 5%) but often provides clues to underlying heart Dz underlying heart Dz E.g. conduction blocks, evidence of CAD or E.g. conduction blocks, evidence of CAD or

LVHLVH Can guide further investigationCan guide further investigation Cheap, non-invasive, fast Cheap, non-invasive, fast Should be done in most ptsShould be done in most pts

Routine LabsRoutine Labs Add very little diagnostic information unless Add very little diagnostic information unless

specific suspicion specific suspicion e.g. hypoglycemia, hyponatremia, ARFe.g. hypoglycemia, hyponatremia, ARF

Can be omitted from work-up if Hx & exam fail Can be omitted from work-up if Hx & exam fail to provide any clues to suspect lab to provide any clues to suspect lab abnormalitiesabnormalities

Pregnancy testing is helpful in select Pregnancy testing is helpful in select circumstancescircumstances

CBC if suspect anemia & DRECBC if suspect anemia & DRE

Stress TestingStress Testing

Utility primarily to rule in & risk-stratify Utility primarily to rule in & risk-stratify CADCAD

Should be preceded by echo in pts with Should be preceded by echo in pts with exertional syncopeexertional syncope

Holter MonitorHolter Monitor Useful if it shows an arrhythmia AND pt is Useful if it shows an arrhythmia AND pt is

symptomatic during the eventsymptomatic during the event Increased duration of monitoring yields Increased duration of monitoring yields

small increases in sensitivity for non-small increases in sensitivity for non-diagnostic arrhythmiasdiagnostic arrhythmias 24h – 19% of pts have arrhythmia (only 4% 24h – 19% of pts have arrhythmia (only 4%

diagnosticdiagnostic 48h – increases to 30% (none ass’d w/ Sx)48h – increases to 30% (none ass’d w/ Sx) 72h – increases to 34% (none ass’d w/ Sx)72h – increases to 34% (none ass’d w/ Sx)

• Bass et al. Arch Int Med 150: 1073-78. 1990Bass et al. Arch Int Med 150: 1073-78. 1990

External Loop RecorderExternal Loop Recorder Similar to Holter w/ transtelephonic Similar to Holter w/ transtelephonic

transmission transmission Activated at Sx onset by ptActivated at Sx onset by pt

postevent monitors – record rhythm for preset postevent monitors – record rhythm for preset time interval after activationtime interval after activation

pre-/postevent monitors – records preset time pre-/postevent monitors – records preset time intervals before and after event intervals before and after event

Used primarily in pts w/ frequent syncopal Used primarily in pts w/ frequent syncopal events who had negative Holtersevents who had negative Holters

Limited if pt unable to activate monitorLimited if pt unable to activate monitor

Insertable Loop RecorderInsertable Loop Recorder

Same as external loop monitors but Same as external loop monitors but implanted like a pacemaker for 18 mo at a implanted like a pacemaker for 18 mo at a timetime

Indications not clearly defined yet but have Indications not clearly defined yet but have been used in pts w/ recurrent syncope been used in pts w/ recurrent syncope NYD after standard investigationsNYD after standard investigations 27% yield for arrhythmia while symptomatic27% yield for arrhythmia while symptomatic 32% yield for NSR while symptomatic32% yield for NSR while symptomatic

EEGEEG

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

Head CTHead CT

Overall yield ~4% in syncopal ptsOverall yield ~4% in syncopal pts all positive findings in pts with focal neuro all positive findings in pts with focal neuro

findings or witnessed Sz’sfindings or witnessed Sz’s Indicated for pts w/ syncope and:Indicated for pts w/ syncope and:

focal neuro signs or Sxfocal neuro signs or Sx SeizureSeizure Head traumaHead trauma

Carotid Sinus MassageCarotid Sinus Massage Test for carotid sinus hypersensitivityTest for carotid sinus hypersensitivity

suggested by Hx of syncope w/ head turning, suggested by Hx of syncope w/ head turning, tight collars, shaving etctight collars, shaving etc

positive test = reproduction of Sx andpositive test = reproduction of Sx and• asystole > 3 sec (cardioinhibitory response)asystole > 3 sec (cardioinhibitory response)oror• 50 mm Hg drop in SBP (vasodepressor response)50 mm Hg drop in SBP (vasodepressor response)

Pts w/ a positive test are candidates for Pts w/ a positive test are candidates for consideration of a pacemakerconsideration of a pacemaker

Incidence of permanent neurologic sequelae is Incidence of permanent neurologic sequelae is 0.03%, and transient deficits ~0.1%0.03%, and transient deficits ~0.1%

Vasovagal SyncopeVasovagal Syncope

Historical predictive featuresHistorical predictive features age <55age <55 femalefemale obvious precipitating eventobvious precipitating event antecedent diaphoresisantecedent diaphoresis antecedent palpitationsantecedent palpitations post-event fatiguepost-event fatigue duration of recovery > 1 minduration of recovery > 1 min

Risk EstimationRisk EstimationOsservatorio Epidemiologico sulla Sincope nel Lazio ScoreOsservatorio Epidemiologico sulla Sincope nel Lazio Score

OESIL Risk ScoreOESIL Risk Score Age >65Age >65 PMHx of any cardiovascular dzPMHx of any cardiovascular dz Syncope without prodromeSyncope without prodrome Abnormal ECGAbnormal ECG

ScoreScore Mortality at 12 mo (%)Mortality at 12 mo (%)00 0011 0.80.822 19.619.633 34.734.744 57.157.1

Colivicchi et al Eur Heart J 24: 811-19. 2003

Driving & SyncopeDriving & Syncope Canadian GuidelinesCanadian Guidelines

private vehiclesprivate vehicles• refrain from driving for 1 month after each syncopal refrain from driving for 1 month after each syncopal

episode if 1 or less episodes per yrepisode if 1 or less episodes per yr• refrain from driving for 3 months after each refrain from driving for 3 months after each

syncopal episode if > 1 per yrsyncopal episode if > 1 per yr commercial vehiclescommercial vehicles

• refrain from driving for 3 months after each refrain from driving for 3 months after each syncopal episode if 1 or less episodes per yrsyncopal episode if 1 or less episodes per yr

• refrain from driving for 12 months after each refrain from driving for 12 months after each syncopal episode if > 1 per yrsyncopal episode if > 1 per yr

Diagnostic AlgorithmDiagnostic Algorithm

Rosen’s Textbook of Emergency Medicine 2002