Dizziness and Vertigo (Case 57)

Lana Zhovtis Ryerson MD and Stephen Krieger MD

Case: A 34-year-old woman presents to the ED with dizziness. She states that 2 days ago she began to feel a “spinning sensation” and was walking around “as though she were drunk.” These symptoms worsened the day before admission, when she developed nausea and vomiting and had increasing difficulty walking. She has no significant past medical history. On exam she has beating nystagmus in all directions of gaze, worse when looking to the right. She has a slightly flattened right nasolabial fold. She has full strength and an intact sensory exam, but on coordination testing she has significant postural instability, as well as dysmetria in the right arm. She is unable to tandem walk, falling to the side.

Differential Diagnosis

Vertigo	Dizziness/presyncope/light-headedness
Benign paroxysmal positional vertigo (BPPV)	Orthostatic hypotension
Acute labyrinthitis/vestibular neuritis	Cardiac arrhythmia
Meniere disease	Vasovagal disorder
Cerebellar infarction or hemorrhage	Intoxication/medication side effects
Perilymphatic fistula	Anxiety

Speaking Intelligently

“Dizziness” refers to a variety of abnormal sensations relating to perception of the body’s relationship to space. What can be difficult for both a patient and the physician is the subjectivity of the term dizziness; people use it to describe an array of abnormal sensations. Furthermore, patients may use different terms to describe the same kind of abnormal sensation, and one must clarify what patients are experiencing when beginning to characterize their symptoms.

Although prevalence studies vary in their definition of the symptom, dizziness is common in all age groups, and its prevalence increases modestly with age. While peripheral vestibular etiologies are among the most common causes, as many as 25% of patients with risk factors for stroke who present to the emergency medical setting with the combination of vertigo, nystagmus, and postural instability may have a stroke affecting the cerebellum.

For most patients the symptom of dizziness resolves spontaneously, but an important minority of patients can develop chronic, disabling symptoms. Patients with chronic dizziness may benefit from an approach aimed at identifying and managing treatable conditions, whether etiologic or contributory. This approach may include correcting visual impairment, improving muscle strength, adjusting medication regimens, identifying and treating psychological comorbidities such as anxiety and depression, and instructing patients on vestibular exercises.

PATIENT CARE

Clinical Thinking

• The first step in evaluating a patient with dizziness is to take a detailed history focusing on the meaning of the term “dizziness” to the patient and to classify his or her symptoms into vertigo as opposed to presyncopal light-headedness.

• Vertigo is an illusory sensation of motion of either oneself or one’s surroundings.

• Presyncope is described as a light-headed, faint feeling, as though one were about to pass out, that is usually due to transient reduction of cerebral blood flow.

• If the symptoms are suggestive of vertigo, the next question that arises is whether the history and findings on examination are consistent with a central disorder such as hemorrhage/infarction of the cerebellum or a peripheral vestibular etiology such as benign positional vertigo or vestibular neuritis.

• It is vital that physicians are able to differentiate the two pathologic localizations, since central causes of acute vertigo, such as cerebellar hemorrhage and infarction, can be life-threatening and may require immediate intervention.

History

When evaluating a complaint of dizziness to establish if there is frank vertigo or presyncope, questions to consider include the following:

• Is there a true sensation of movement or spinning?

• Is there a feeling of faintness and light-headedness?

• Are there vague, persistent feelings of imbalance?

• What are the associated characteristics?

• Nausea/vomiting may accompany vertigo.

• The sensation of warmth, diaphoresis, and visual blurring may indicate presyncope.

• Palpitations, dyspnea, or chest discomfort can indicate a cardiac cause.

• What is the duration of the episodes, and what are any exacerbating factors (e.g., head movement)?

• Has syncope ever occurred during an episode?

• Do episodes occur only when the patient is upright, or do they occur in other positions?

Physical Examination

• If presyncope is suspected, the physical exam should include evaluation of heart rate and blood pressure in the supine, sitting, and standing positions to evaluate for orthostatic hypotension. Assessment of the pulse and direct cardiac auscultation may assist in determining if the episode is associated with arrhythmia.

• When vertigo is suspected, the clinical exam, with particular attention to nystagmus, helps to distinguish between peripheral and central vestibular etiologies.

Feature of Nystagmus	Peripheral (Labyrinth or Nerve)	Central (Brainstem or Cerebellum)
Latency of nystagmus	3–40 sec	None: immediate vertigo and nystagmus
Fatigability of nystagmus	Yes	No
Direction of nystagmus	Unidirectional, often rotatory	Can be bidirectional, unidirectional, or vertical
Visual fixation	Inhibits nystagmus and vertigo	No inhibition
Intensity of vertigo	Severe	Mild
Tinnitus and/or hearing loss	Often present	Usually absent
Associated CNS abnormalities	None	Extremely common (e.g., diplopia, hiccups, cranial neuropathies, dysarthria)
Common causes	BPPV, vestibular neuritis, labyrinthitis, Meniere disease	Infarction, hemorrhage, multiple sclerosis, neoplasm

Figure 65-1 The Dix-Hallpike maneuver. With the patient sitting on the exam table (facing forward and eyes open), the physician turns the patient’s head 45 degrees to the right (A). The physician then supports the patient’s head as the patient lies back quickly from a sitting to a supine position, ending with the head hanging 30 degrees off the end of the examination table. The patient remains in this position for 30 seconds (B). Next the maneuver is repeated with the patient’s head initially turned to the left. A positive test is indicated if any of these maneuvers produce vertigo with or without nystagmus.

Tests for Consideration

• If stroke or hemorrhage is suspected, laboratory studies including CBC and prothrombin time/partial thromboplastin time (PT/PTT) should be performed. Other tests that may be helpful when evaluating peripheral vertigo in the outpatient setting include electronystagmography (ENG) and audiography.

$11, $15, $185, $85

IMAGING CONSIDERATIONS

→ Brain MRI (with attention to the cerebellum and posterior fossa) is recommended when the examination of a patient with an acute vestibular syndrome yields findings suggestive of a central localization. Urgent imaging is also recommended when the onset of symptoms is sudden in a patient with prominent risk factors for stroke or when a new-onset headache accompanies the acute vertigo.	$534
→ If prompt brain MRI is not available, head CT should be performed, with fine cuts through the cerebellum.	$334