EMed

Vertigo

Vertigo

An illusion of motion where no motion exists (not to be confused with syncope/pre-syncope).

Seek details of:

  • Onset
  • Duration
  • Repetition
  • Hearing/tinnitus
  • Headache
  • Vomiting
  • Diplopia
  • Recent medication

Differentiate between central and peripheral vertigo, since the former are almost always a result of serious pathology

“Red flags” for posterior circ. stroke

  • Sudden onset vertigo or disequilibrium with one or more additional posterior circulation symptoms:
    • Headache
    • Gait or limb ataxia
    • Visual change (diplopia or field loss)
    • Dysarthria, dysphagia
    • Limb weakness
  • Sudden onset vertigo or disequilibrium with a HINTS examination suggesting a central cause
  • Hx migraine, presentation with any new posterior circulation symptoms, even if these occur with headache

Ask a senior to review if there are any two new acute onset posterior circulation symptoms (especially if there are risk factors for stroke) or any new focal posterior circulation neurological signs.

Clinical

Central

  • Less intense
  • Not positional
  • Hearing rarely affected
  • Nystagmus not ↓ by ocular fixation
  • Brain stem /cerebellar signs

Hallpike (with central)

Should only be completed on patients with brief (<30 sec.) episodes and no vertigo/spontaneous nystagmus at exam. time.

  • No latency of nystagmus
  • Nystagmus non-fatiguing
  • Multidirectional
  • Vertigo lasts >1min

Peripheral

  • Intense spinning / swaying
  • Aggravated by position
  • Altered hearing / tinnitus
  • Horizontal nystagmus is unidirectional (unaffected by gaze direction)
  • Nystagmus ↓ by ocular fixation
  • Nystagmus fast phase worse looking away from damaged labyrinth

Hallpike (with peripheral)

  • 2-20s latency
  • fatigue with repeat testing
  • unidirectional
  • <1min
Hallpike
*patient sitting on trolley, rapidly lowered to supine position with physician controlling head. Head rotated 45° left then right.
Examples of Common Peripheral, Central & patters of Nystagmus

Pattern

Nystagmus

Typical causes

Peripheral *

 Burst of upbeat-torsional nystagmus, lasting < 30 seconds, triggered by the Dix-Hallpike test to one side.
Unidirectional spontaneous (i.e., primary gaze) nystagmus, with ↑ in velocity in the direction of the nystagmus fast phase and ↓ velocity in the opposite direction. E.g. left beating nystagmus in primary gaze, with an increase in velocity with left gaze, and a decrease (but not reversal) with right gaze.		 BPPV
Vestibular neuronitis

Central

 Spontaneous vertical nystagmus (upbeat or downbeat)
Gaze-evoked direction changing nystagmus (i.e., persistent left beating on left gaze and then persistent right beating on right gaze)
Persistent down-beating nystagmus triggered by a positional test such as the Dix-Hallpike test.		 Stroke
MS
Chiari malformation
Meds: (e.g., antiepileptics)
Cerebellar degen. disorder

The Dix-Hallpike test should only be used for patients with short (30 sec) episodes of vertigo with head movement and no spontaneous nystagmus.

§ The Dix-Hallpike test is a specific positional test to asses for positional nystagmus. The patient sits upright and the head is turned about 45° to one side. The patient is then quickly guided by the physician down to a supine position with the head extended over the end of the examining table. In this position, the eyes are observed for nystagmus triggered by the test. The patient is then brought back to the sitting position and the test is then repeated with the head turned to the opposite side.

BPPV = benign paroxysmal positional vertigo.

* For peripheral vestibular nystagmus, the velocity of nystagmus typically increases by inhibiting visual fixation and decreases by encouraging visual fixation.

HINTS test

"Head-Impulse"-"Nystagmus"-"Test-of-Skew"

The patient must have ongoing vertigo & spontaneous nystagmus at the time of testing.

HI = Horizontal Head Impulse Test (h-HIT)

The HIT is abnormal with vestibular neuritis (nerve issue, so reassuringly, not a central lesion).

Abnormal is good! (in someone with vertigo).

HIT also normal in normal patient (so must only be interpreted in a patient who still has vertigo and nystagmus at the time of exam).

  • Ask patient to look at your nose
  • Rotate patient's head R and L 20° then rapidly back to mid-line
  • Look for "catch-up" saccade

N = Nystagmus test

Check for nystagmus - primary (central) and lateral gaze (no fixation).

  • Patients with AVS show a dominantly horizontal unidirectional (direction of nystagmus unaffected by changed in gaze direction) nystagmus, which beats only in one direction and ↑ in intensity when the patient looks in the direction of the nystagmus fast phase (AWAY from the offending labyrinth)
  • Patients with a central cause may exhibit a change in the direction of eccentric gaze

TS = Test of Skew

A vertical ocular misalignment which results from an imbalance in neural firing when there is a central stroke/lesion.

  • Patient looks at your nose
  • Cover, then rapidly uncover one eye
  • Look to see if the uncovered eye re-aligns vertically
  • Repeat with other eye

Interpreting HINTS

Reassuring HINTS exam:

Must have all 3 of:

  • Unidirectional nystagmus
  • No vertical skew deviation
  • Abnormal HIT but only in one direction

A dangerous HINTS:

Has any of the 3 below:

  • Normal Head Impulse Test
  • Direction-changing nystagmus
  • Any skew deviation

The HINTS exam is more sensitive and specific than general neurological signs or than MRI in detecting medullary/pontine stroke.

Causes

Causes of central vertigo

  • Cerebellar infarct/bleed **
  • Brain-stem:
    • CVA e.g. lateral medullary syndrome
    • Other infarcts of caudal pons
    • Neoplasm
    • MS
  • Trauma

Unilateral sensorineural loss needs tumour exclusion (ENT OPD). The whisper test with finger-rub distraction should be followed up with Rinne's and Weber's to establish basis of hearing deficit.

NOTE: - cerebellar haemorrhage suggested by acute ataxia and vertigo ± headache ± nausea and vomiting with no paralysis is a neurosurgical emergency and requires urgent CT & neurosurgical opinion

Peripheral causes of vertigo

  • Meniere's: Triad of bouts of vertigo, tinnitus & progressive deafness
  • Vestibular neuronitis: no hearing loss
  • BPPV: particularly provoked by altered position
  • Drugs:
    • Aspirin affects the cochlea giving rise to tinnitus
    • Aminoglycosides affect vestibular apparatus primarily
  • Suppurative labyrinthitis: from recurrent otitis media / mastoiditis etc
  • Acoustic schwannoma & meningioma: gradual onset, pre-ceded by hearing loss

Treatment

Peripheral features positive

Central features positive

  • Treatment as per cause
  • Urgent MRI/CT if ? cerebellar lesion / base skull #
  • Neurology review if ? MS
  • Refer stroke team (CT "code stroke")if ? CVA

Drug treatment

  • Stemetil 5mg tds, Antihistamines (e.g. cyclizine PO tds)

Content by Dr William Sargent, Dr Íomhar O' Sullivan. Last review Dr ÍOS 25/03/24.