Inpatient Evaluation of The “Dizzy” Patient

Jaclyn Laine DO, APBN

OhioHealth Neurological Physicians

Objectives:

• Identify key history leading to more accurate diagnosis• Distinguish clinical features of central versus peripheral

etiology • Determine the “red flag” symptoms for pathologic vertigo

Anatomy

• Peripheral Vestibular System

– Vestibular aparatus: semicircular canals, utricle saccule and CN VIII- vestibular nerve

• Central Vestibular System

– Vestibular nuclei at the ponto-medullary junction, cerebellum, midbrain

Consensus Definitions for Vestibular Symptoms

• Vertigo

– The sensation of self -motion with no motion is occurring or distorted self motion during normal head movements

• Dizziness

– The sensation of disturbed or impaired spatial orientation without a false or distorted sense of motion

• Unsteadiness• Feeling of being unstable without a particular directional preference

• Oscilopsia

– The false sense that the visual surround is oscillating

Timing is the most important detail !

• Acuity

– Acute or chronic

• Provoking nature

– Spontaneous or positional

• Episodic or prolonged

– Seconds, minutes, hours, days

– Fluctuations or no symptoms between episodes

Key Points in Past Medical history

• History of migraine

– With aura or vertigo induced by movement in surrounding

• Atherosclerotic risk factors

• CAD, known orthostasis

• Head trauma

• Medications: lithium, TCA’s ototoxic antibiotics, alcohol, AED’s

• Features pointing towards central etiology:

– Exam with postural and gait instability

– Nystagmus can be any direction, however

• Sometimes reverses direction when patient looks in the direction of slow component

• Features pointing towards peripheral etiology

– Aural fullness, Hearing loss, tinnitus

– Sensation of instability - not wanting to walk

• Exam with normal posture and gait

– Nystamgus torsional horizontal, not purely vertical, doesn’t reverse direction

• Vertigo is not continuous for more than a few weeks.

• Even with permanent lesions the central nervous system adapts to the defect so that vertigo subsides over several weeks.

• Constant dizziness lasting months is usually psychogenic, not vestibular.

– Some patients who say they have constant dizziness for months actually mean that they are susceptible to frequent episodic dizziness.

Common Categories of Vestibular Symptoms

1. Acute, Spontaneous and prolonged– (Acute vestibular syndrome)

2. Episodic, positional– (BPPV and central mimics)

3. Episodic spontaneous

– (Vestibular migraine, Meniere's, TIA )

4. Chronic unsteadiness -with/without oscilopsia– (Oscilopisa at rest – nystagmus brain stem lesion)

– (Oscilopsia with head motion - bilateral vestibular failure)

New onset dizzinessCommon causes and dangerous Mimis

BENIGNBENIGN Dangerous MimicsDangerous Mimics

Seconds to hours- episodic– BPPV TIA, Cardiac Arrythmia– Orthostatic hypotention MI, PE, GI bleed

– Reflex syncope Aortic dissection, atrial myoxma

Days to weeks- continuous– Viral labrynthitis Brainstem/ cerebellar stroke– Vestibular neuritis Bacterial labrinthitis/mastoiditis– Medication toxicity Herpes zoster oticus

Anticonvulsants Brainstem encephalitis

Wernicke Syndrome

Toxic – lithium, etoh withdrawal CO exposure

Key points

• Vestibular dizziness is always exacerbated or provoked by head movement

– At least in the acute phase

– No matter if peripheral or central in origin

• Clear reproducible triggers for non-exertional vestibular symptoms generally indicate a benign cause

Case #1

• 25 year old woman presented with recent episodic dizziness and headache. This occurred spontaneously one or twice a week during the prior 6 weeks. Lasting 5-10 minutes. No associated neurologic symptoms were present. The pain was located behind the left year and present throughout the last six weeks without variation of severity.

– Personal history of episodic migraine holocephalic, nausea, throbbing, dizziness, family history of migraine, no history of vascular risk factors

Case Considerations

• Sounds like Vestibular migraine– Young, female, personal history of migraine with

“dizziness”– However non-flucuating continuous head pain with

referral to ear?

– What questions are missing? • History of trauma• History or recent illness, fever, ear drainage• History of aural fullness, tinnitus hearing changes

Further questioning

• Reveals head and neck trauma from carrying a mattress about 2 months ago

• Continuous headache and lack of fluctuating points to a fixed structural pathology

Imaging

CTA head and neck with attention to temporal bones

looking for mastoiditis, vascular structural pathology

Imaging revealed a vertebral artery dissection

Quick Tips

• Protective P’s

• If old and recurrent

– Periodic, Prolonged

• Recurrent Stereotyped episodes over years

• If symptoms are acute/subacute

• Painless

– IF painful

Red flags:

sudden < 30 minutes, severe, sustained >72 hours

Points to Remember

• Deadly D’s

Indicating vascular brainstem symptoms

• Diplopia

• Dysarthria

• Dysphagia

• Dysmetria ( clumsiness)

• Dysethesias (specific facial numbness)

• Drop attacks

• Down is up distortions ( room inverted)

• NO dyspnea ( cardiopulmonary)

• NO deafness ( vascular inner ear)

Case 2#

• 71 year old man presented with several months of episodic spinning, lightheadedness and imbalance

– Last episode occurred for 10 seconds when her got our of been. He sat down and felt normal within in 20 seconds

– He has been awakened by a spinning sensation

– A more recent spell was described at lightheadness with standing in line at the grocery store

– Neurological Exam and imaging normal, cardiac work up with Echo and EKG normal

– Dix halpike showed nystagmus with left head position

– Vestibular rehab improved symptoms, however continued to have symptoms walking

– His continued symptoms warranted investigation and with orthostatic vital signs were not significant

– Tilt table revealed BP to 75 systolic with normal HR and BP

• Blood pressure meds adjusted

• Low dose fludrocortisone

• Behavioral strategites

– This illustrates that the original history described two types of “dizziness”

Case 3#

• 26 year old male presents with 3 days of recurrent, severe dizzy episodes with ear fullness and sensitivity to sound. some last for 30 seconds, some for 10 minutes. This is brought on by exertional activities. He moved to a new apartment in the last week.

• Perilymph Fistula

• Episodic dizziness without true vertigo

• Associated with heightened hearing or loss of hearing

• Provoked by coughing or vasovagal

• Caused by head trauma, heavy lifting, SCUBA

– Diagnosis: ENT, valsaval with nystagmus, MRI not usually helpful, temporal bone CT rules out other pathology,

– Treatment: ENT

• Strict bed rest

• Possible surgery

Case #4

51 year old woman who noted sensation of her

right ear ‘being blocked’ this AM. • Now has ringing and decreased hearing The room then began to spin wildly   She became diaphoretic, nauseated and vomited •  The spinning lasted about 60 minutes, then abated •  She now has a sensation of residual dysequilibrium several hours later

Case #5

• 50 y/o woman suddenly feels overwhelming tilting sensation, feels her legs become rigid and abruptly falls to the ground Recovers to normal after a few seconds

• Prior history at age 43 of single episode of tinnitus with dizziness lasting several hours with complete resolution

Diagnosis in both cases

• Meniere’s

• Both are characteristic variants

Meniere’s

•   Two or more definitive spontaneous episodes of vertigo 20 minutes or longer

• Audiometrically documented hearing loss on at least one occasion

•   Tinnitus or aural fullness

•   Other causes excluded

Probable Meniere's

• One definitive episode of vertigo

•  Audiometrically documented hearing loss on at least one

• occasion

•  Tinnitus or aural fullness

• Other causes excluded

Treatment

• Diazide diuretic

• Strict low Na intake

• Vestibular suppressant

• Stress Reduction

– In severe cases surgical management

Eye movement testing

• A word on nystagmus. . .

– No one likes to interpret it

High Points:

– Nystagmus that fatigues- peripheral

– Persistent downbeat- central

– Pathologic Gaze evoked nystagmus

• Vertical ( central)

• Asymmetric

• Present within 30 degrees of primary gaze

Case 6

• 65 year old female with history of mild imbalance and more episodes of vertigo when lying in bed at night.

• Examination shows:

• subtle downbeat nystagmus when gazine right and left

• Dix hallpike in both directions triggers downbeat nystagmus only

Where is the most likely localization?

A: cerebellum

B:lateral semicircular canal

C: vestibular nerve right

D: saccule

• Cerebellum

• Gazed evoke downbeat nystagmus

• Persistent positional downbeat nystagmus

• Despite central etiology- cerebellar lesions can cause prominent positional symptoms

Conclusions

• Initial history for subjective sensation and associated symptoms is key in establishing appropriate differential

• Always perform eye movement testing, coordination testing, and gait testing

• Timing of symptoms is more important than subjective description