Tag Archives: vertigo

Posterior Circulation Strokes and Dizziness: Pearls and Pitfalls

Authors: Alec Pawlukiewicz, BA (Vanderbilt University School of Medicine) and Drew A. Long, BS (@drewlong2232, Vanderbilt University School of Medicine) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)

Case Presentation

You are working the night shift in the ED, and you see the next patient is a 38-year-old female complaining of dizziness.  Her vital signs include HR 82, BP 115/70, RR 12, O2 saturation 99%, and T 37 C.  She describes her dizziness as a sensation of the room spinning, and her dizziness began yesterday and has worsened today.  It is associated with severe nausea and vomiting. Her past medical history is notable for type I diabetes.  She has never had any previous episodes of dizziness.  Is she having a posterior stroke? How can you evaluate this patient for a life-threatening cause of dizziness?

Background

Worldwide, stroke is a major cause of disability and mortality.1  In the U.S., around 795,000 strokes occur every year.2 Posterior circulation strokes account for approximately 20% of ischemic strokes.3 Unfortunately, many of these posterior strokes are initially misdiagnosed or remain undiagnosed.4 Misdiagnosis of posterior circulation strokes presenting with dizziness is common, occurring in up to 35% of cases.5 The common causes of posterior circulation strokes include embolic causes, atherosclerosis (and subsequent stenosis), small vessel disease, and arterial dissection.6-9 The posterior circulation supplies approximately 20% of the brain.10  See Figure 1 for the anatomy of the posterior circulation and Table 1 for the areas supplied.

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Table 1: Areas Supplied by Posterior Circulation11

Artery Area Supplied
Vertebral Artery Brainstem
PICA Cerebellum
Basilar Artery Thalamus
Posterior cerebral Auditory/vestibular structures
Medial temporal lobe Visual occipital cortex

Clinical Presentation

The clinical presentation of posterior circulation strokes can vary widely and depends on the location of the infarct. Posterior circulation strokes commonly present with symptoms of altered mental status, vision changes, speech changes, nystagmus, vertigo, ataxia, limb weakness, headache, and a variety of other focal neurological deficits.12,13 Of note, these focal neurological deficits may be absent or subtle, leading to difficulty diagnosing posterior strokes.13,14 One particularly challenging presentation of posterior circulation stroke is patients with acute vestibular syndrome (AVS), which often manifests with vertigo or “dizziness.”  This review will focus on dizziness or vertigo and the posterior circulation.

Categorizing Dizziness

A common, classic first step in evaluating a patient with dizziness is to have them characterize what they mean by “dizzy,” as dizziness is an imprecise descriptor.  Dizziness is often used by patients to describe a wide variety of experiences, which can be categorized into one of four categories.  These include vertigo (illusion of motion, often spinning), near syncope (feeling of impending fainting), disequilibrium (loss of balance while walking), and nonspecific dizziness.15  Unfortunately, having the patient describe what they mean by “dizzy” has been shown to be an unreliable indicator of the underlying pathology.16,17  A study by Newman-Toker et al. found that patients frequently changed their descriptors of the type of dizziness if questioned in a different manner after only 10 minutes.18 These studies bring into question the utility of a patient’s description and characterization of “dizziness.”

A newer method of categorizing “dizziness” deals with the timing and triggers of its onset.14 One study has shown that despite the unreliability of the description of the dizziness, patients often reliably relate the context and timing of its onset.19 These categories are displayed in Table 2.

Table 2.  Categories of Timing and Triggered Based Vestibular Syndromes14

Vestibular Syndrome  Duration Asymptomatic Periods Triggers?
Acute Vestibular Syndrome > 24 Hours No No
Triggered Episodic Vestibular Syndrome < 1 minute Yes Yes
Spontaneous Episodic Vestibular Syndrome Minutes to hours Yes No, but may have exacerbating factors

Vestibular Syndromes include Acute Vestibular Syndrome (AVS), Triggered Episodic Vestibular Syndrome, and Spontaneous Episodic Vestibular Syndrome.  Table 2 lists defining characteristics of these syndromes. Table 3 lists common benign and dangerous causes of these categories of dizziness. The dizziness associated with posterior circulation strokes often falls into the category of AVS.  AVS is characterized by a rapid onset of vertigo, in addition to nausea/vomiting and gait unsteadiness.  AVS is often associated with head motion intolerance and nystagmus that can last for days to weeks.20

Table 3. Benign and Dangerous Causes of Dizziness14

Vestibular Syndrome Common Benign Cause Dangerous Cause(s)
Acute Vestibular Syndrome Vestibular neuritis Stroke
Triggered Episode Vestibular Syndrome BPPV Posterior Fossa Tumor
Spontaneous Episodic Vestibular Syndrome Vestibular migraine TIA, Cardiac Dysrhythmia

Peripheral vs. Central Causes of AVS

The differential diagnosis of AVS can be broken into peripheral and central causes. It is imperative the Emergency Physician consider central causes of vertigo. Central causes include those disorders that affect the structures of the central nervous system such as the cerebellum and the brainstem. The most common, dangerous central cause of AVS is a posterior circulation stroke. Peripheral causes are those that affect CN VIII and the vestibular apparatus.  The most common peripheral causes of AVS are vestibular neuritis and labyrinthitis.20 A list of signs and symptoms associated with peripheral and central causes is shown in Table 4. The Emergency Physician (EP) must keep in mind many of the distinguishing features of peripheral lesions may also be present in central lesions. For example, while auditory symptoms are typically associated with peripheral processes, their presence does not exclude a central process.21

The evaluation for stroke in AVS is particularly important in those patients who are older, have hypertension or cardiovascular disease, are on anticoagulation, or have other classic stroke risk factors.22 However, the EP must keep in mind younger age is not sufficient reason to exclude the potential diagnosis of stroke. It is estimated one in five strokes causing AVS affects a patient less than 50 years of age and one in ten patients less than 40 years of age.20 One study found 50% of patients misdiagnosed after suffering a posterior circulation stroke were under the age of 50.23 The overall mortality described by this study was 40%, with a 50% prevalence of significant neurological disability among the survivors.23 These findings convey the significance of thorough assessment for central pathologies in patients with AVS.

Table 4: Signs/ Symptoms Differentiating Peripheral and Central Vertigo22

Peripheral Central
Onset Sudden or Insidious Sudden
Severity of Vertigo Intense Spinning Ill-defined, may be severe or less intense
Prodromal Dizziness Occurs in up to 25%, often single episode Occurs in up to 25%, recurrent episodes suggest TIA’s
Intolerant of head movements/Dix-Hallpike Maneuver Yes Varies, but often intolerant
Associated Nausea/Diaphoresis Frequent Variable, but often frequent
Auditory Symptoms Points to peripheral causes May be present
Proportionality of Symptoms Usually proportional Often disproportionate
Headache/Neck Pain Unusual More likely
CNS signs/symptoms Absent Usually present
Head Impulse Test Abnormal Often normal
Nystagmus Horizontal Vertical/direction-changing
HINTS Testing Negative Abnormal in at least 1 out of 3 tests

Physical Exam

A focused neurological exam, including gait assessment, speech, and cranial nerves, in patients presenting with AVS is needed. Focal neurological deficits are consistent with a central cause of AVS. However, the absence of neurological deficits does not exclude a central cause. One review of AVS secondary to strokes found focal neurological deficits were present in 80% of cases.24 Additionally, Dix-Hallpike testing, while effective in diagnosing BPPV (a cause of triggered episodic vestibular syndrome), provides no diagnostic utility in the assessment of AVS.14 A potential tool for the Emergency Physician in evaluating patients with AVS is the HINTS examination.

HINTS Testing

HINTS testing is a three-part examination that consists of head impulse testing, nystagmus assessment, and test of skew. This test is the gold standard for diagnosis of posterior circulation strokes, as its sensitivity is higher than any imaging modality in the first 24-48 hours after symptom onset.  The HINTS test should  be used in patient complaining of continuous feelings of vertigo or dizziness, where concern for AVS is present.  It is not useful in patients with momentary position-related vertigo or patients with TIAs who are not dizzy when examined.25 For a great overview, see EMCrit at https://emcrit.org/podcasts/posterior-stroke/.

The first component of the HINTS test is head impulse testing.  Head impulse testing consists of having the patient visually fixate on a target followed by a rapid 40 degree head turn. This process is then repeated in the other direction. A unilateral abnormal finding (saccade) is consistent with a peripheral process and a normal response (no saccade) to this testing is consistent with a central process (Kattah, Edlow).14,20  This test is depicted in Figure 2 and an abnormal response is shown in Video 1.

Video 1: Abnormal Head Impulse Test

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The second component of the HINTS test is assessment of nystagmus, which analyzes the characteristics of nystagmus during lateral gaze at 45-60 degrees, not at end-gaze. Direction changing nystagmus is consistent with a central cause of AVS and unidirectional horizontal nystagmus is more consistent with a peripheral cause. Assessment of nystagmus is specific but not sensitive for a central cause of AVS.22 Vertical or torsional nystagmus in a patient with AVS is a sign of a central etiology.  However, strokes presenting with AVS may have a normal (horizontal) finding of nystagmus.20 A study by Lee et al. found that approximately half of pseudolabyrinthine strokes present with unilateral, horizontal findings of nystagmus.26

The final component of the HINTS test is the test of skew, which assesses ocular misalignment. This is determined using the alternating cover test, which consists of covering one eye and then assessing for any movement/re-fixation when the eye is uncovered. Any realignment is consistent with a central process. An abnormal test of skew is shown in Video 2. This test is also specific but not sensitive for central causes of AVS.22

Video 2: Abnormal Test of Skew

A helpful mnemonic for the HINTS testing results that are consistent with central causes is INFARCT (Impulse Normal, Fast-phase Alternating, Refixation on Cover Test).20

Table 5.  INFARCT mnemonic for HINTS findings suggestive of central cause of vertigo.20

INFARCT mnemonic
Impulse Normal
Fast-phase Alternating
Refixation on Cover Test

Buyers Beware…

Many of the studies evaluating the HINTS exam utilized neuro-ophthalmologists with specialized equipment and training, often in patients not in the ED. Thus, translating this to regular ED practice must be done with caution. A slow-motion camera (there are several apps available for phone use) can assist in detecting subtle ocular findings. More studies are needed evaluating the HINTS exam conducted by emergency physicians on ED patients. For more potential pitfalls in the ED, please see EMCrit at https://emcrit.org/emnerd/adventure-veiled-lodger/.

Imaging

What is the role of imaging in the ED evaluation of patients with vertigo?  Patients with physical exam findings concerning for a central process require urgent imaging to assess for hemorrhage, infarction, or tumor.22 In regards to the type of imaging, MRI in addition to CT is preferred due to poor visualization of the posterior fossa with CT.27 The sensitivity of brain CT for posterior circulation infarcts is only 7-42%.28-31 However, even a negative MRI does not rule out a posterior circulation stroke in patients with a high clinical suspicion for a central cause.  MRI with DWI within the first 48 hours of infarction may miss up to 10-20% of posterior circulation strokes.32

The most important tool to evaluate for a central cause in patients with AVS is the HINTS exam performed by an experienced physician.  In the evaluation of posterior circulation stroke, Kattah et al. examined the various methods for diagnosis, shown in Figure 3.20 An abnormal HINTS test has been shown to be 100% sensitive and 96% specific for the detection of central causes of AVS, making it more sensitive than even MRI in the first 24-48 hours.20  Furthermore, a brain MRI takes at least 5-10 minutes to conduct not considering wait time, in addition to thousands of dollars in cost.  The HINTS test can be done in minutes at no additional cost.

Figure 3.  Diagnostic Modalities for Posterior Circulation Stroke20

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Disposition

In considering the disposition of these patients, Edlow et al. in 2015 recommended disposition criteria.14 They recommended a patient presenting with AVS is likely safe to go home if:

  • Patient is able to sit and stand independently
  • Patient has no cranial or cerebellar signs
  • Patient has HINTS testing suggestive of a peripheral process

 HINTS exam results indicative of peripheral vertigo are unidirectional, horizontal nystagmus, unilaterally abnormal head impulse test, and normal vertical eye alignment (no skew).  Together, these findings reduce the odds of a stroke by at least 50 fold.24

Pearls and Pitfalls

Pearls

  • Clarify what the patient means by dizziness regarding timing and triggers of the onset of symptoms. Distinguish dizziness from syncope or other mimicking conditions, as these will require a different work-up.
  • Suspect a central etiology in patients with acute vestibular syndrome. Evaluate with the HINTS exam.
  • Use the HINTS test in patients presenting with Acute Vestibular Syndrome, as this is more sensitive than both CT and MRI for posterior circulation strokes.
  • Nystagmus is assessed during lateral gaze at 45-60 degrees, not at end-gaze. An abnormal response in a patient with AVS is vertical or torsional nystagmus. 
  • The HINTS exam should only be used in patients presenting with Acute Vestibular Syndrome, not patients with Triggered or Spontaneous Episodic Vertigo Syndrome.

Pitfalls

  • Symptoms that worsen with movement do not confirm a peripheral process. Symptoms with movement may also exacerbate symptoms from a central process.
  • A normal head CT is not sufficient in excluding ischemic stroke.
  • MRI should not be relied upon in the initial 24-48 hours after symptom onset to rule out a posterior circulation stroke, as it may miss up to 10-20% of posterior circulation strokes.
  • Younger age does not exclude central causes of Acute Vestibular Syndrome. A stroke should still be suspected in patients younger than 50 if the physical exam is concerning for a central process.
  • Many of the classic distinguishing features of peripheral lesions are also found in central lesions.

Case Resolution

You return to the room of the 38 y/o female with dizziness to gather a more detailed history and physical.  You determine that the patient’s dizziness began yesterday morning after she awoke, was constant all day yesterday, and has not resolved today.  She has experienced difficulty walking since yesterday and is still feeling dizzy currently.  Astutely categorizing this patient as exhibiting AVS, you conduct a HINTS exam in addition to a neurologic exam.  The HINTS exam is notable for direction-changing nystagmus and a positive test of skew.  Concerned for a central etiology of this patient’s vertigo, you order a brain MRI in addition to consulting neurology for further workup and management.

 

This post is sponsored by www.ERdocFinder.com, a supporter of FOAM and medical education, who with their sponsorship are making FOAM material more accessible to ER physicians around the world.

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References/Further Reading

  1. Lozano R, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010.
    Lancet. 2012 Dec;380(9859):2095-128.
  2. Mozaffarian D et al.  Heart Disease and Stroke Statistics-2016 Update: A Report From the American Heart Association
  3. Savitz S, Caplan L. Vertebrobasilar Disease. N Engl J Med 2005;352:2618-26
  4. Ferro JM, Pinto AN, Falcao I, et al. Diagnosis of stroke by the nonneurologist: a validation study. Stroke 1998;29:1106-9.
  5. Kerber KA, Brown DL, Lisabeth LD, Smith MA, Morgenstern LB. Stroke among patients with dizziness, vertigo, and imbalance in the emergency department: a population-based study. Stroke. 2006;37: 2484–2487.
  6. Caplan LR, Wityk RJ, Glass TA, et al. New England Medical Center Posterior Circulation Registry. Ann Neurol 2004;56:389-98.
  7. Bogousslavsky J, Van Melle G, Regli F. The Lausanne Stroke Registry: analysis of 1,000 consecutive patients with first stroke. Stroke 1988;19:1083-92.
  8. Moulin T, Tatu L, Vuillier F, Berger E, Chavot D, Rumbach L. Role of a stroke data bank in evaluating cerebral infarction subtypes: patterns and outcome of 1,776 consecutive patients from the Besancon Stroke Registry. Cerebrovasc Dis 2000;10:261-71.
  9. Vemmos K, Takis C, Georgilis K, et al. The Athens Stroke Registry: results of a five-year hospital-based study. Cerebrovasc Dis 2000;10:133-41.
  10. Crocco T, Goldstein J. Stroke. In Marx J, Hockberger R, Walls R. Rosen’s Emergency Medicine. 2014; 8: 1363-1374.
  11. Go S, Worman D. Stroke Syndromes. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. New York, NY: McGraw-Hill; 2016.
  12. Searls  DE, Pazdera  L, Korbel  E, Vysata  O, Caplan  LR: Symptoms and signs of posterior circulation ischemia in the New England Medical Center Posterior Circulation Registry. Arch Neurol. 2012; 69: 346.
  13. Bradley  WG, Daroff  RB, Fenichel  GM, Marsden  CD (eds): Neurology in Clinical Practice, 4th ed. Philadelphia, PA: Butterworth-Heinemann; 2004.
  14. Edlow JA, Newman-Toker D.  Using the Physical Exam to Diagnose Patients with Acute Dizziness and Vertigo.  J Emerg Med.  2016 Apr 50(4):  617-28.
  15. Drachman DA, and Hart CW: An approach to the dizzy patient. Neurology 1972; 22: pp. 323-334
  16. Kerber KA, Newman-Toker DE. Misdiagnosing dizzy patients: common pitfalls in clinical practice. Neurol Clin 2015;33:564–76
  17. Newman-Toker DE, Edlow JA. TiTrATE: a novel approach to diagnosing acute dizziness and vertigo. Neurol Clin 2015;33:577–99.
  18. Newman-Toker DE, Cannon LM, Stofferahn ME, Rothman RE, Hsieh YH, Zee DS. Imprecision in patient reports of dizziness symptom quality: a cross-sectional study conducted in an acute care setting. Mayo Clin Proc 2007;82:1329–40.
  19. Bisdorff A, Staab J, Newman-Toker D. Overview of the international classification of vestibular disorders. Neurol Clin 2015;33: 541–50.
  20. Kattah  JC, Talkad  AV, Wang  DZ, et al.: HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009; 40: 3504.
  21. Lee  H, Kim  JS, Chung  EJ, et al.: Infarction in the territory of anterior inferior cerebellar artery: spectrum of audiovestibular loss. Stroke. 2009; 40: 3745.
  22. Goldman B. Vertigo. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. New York, NY: McGraw-Hill; 2016.
  23. Savitz  SI, Caplan  LR, Edlow  JA: Pitfalls in the diagnosis of cerebellar infarction. Acad Emerg Med. 2007; 14: 63.
  24. Tarnutzer  AA, Berkowitz  AL, Robinson  KA, et al.: Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome. CMAJ. 2011; 183: E571.
  25. Caplan LR. Posterior circulation cerebrovascular syndromes. https://www.uptodate.com/contents/posterior-circulation-cerebrovascular-syndromes. Accessed February 22, 2017.
  26. Lee H, Sohn SI, Cho YW, et al. Cerebellar infarction presenting isolated vertigo: frequency and vascular topographical patterns. Neurology 2006;67:1178–1183.
  27. Kerber  KA, Schweigler  L, West  BT, et al.: Value of computed tomography scans in ED dizziness: analysis from a nationwide representative sample. Am J Emerg Med. 2010; 28: 1030.
  28. Chalela JA, Kidwell CS, Nentwich LM, et al. Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison. Lancet 2007;369:293–8.
  29. Hwang DY, Silva GS, Furie KL, Greer DM. Comparative sensitivity of computed tomography vs. magnetic resonance imaging for detecting acute posterior fossa infarct. J Emerg Med 2012;42:559–65.
  30. Kabra R, Robbie H, Connor SE. Diagnostic yield and impact of MRI for acute ischaemic stroke in patients presenting with dizziness and vertigo. Clin Radiol 2015;70:736–42.
  31. Ozono Y, Kitahara T, Fukushima M, et al. Differential diagnosis of vertigo and dizziness in the emergency department. Acta Otolaryngol 2014;134:140–5.
  32. Saber Tehrani AS, Kattah JC, Mantokoudis G, et al. Small strokes causing severe vertigo: frequency of false-negative MRIs and nonlacunar mechanisms. Neurology 2014;83:169–73.

 

A Simplified Approach to the Patient with Dizziness

Author: Jacob Lotstein, MD (EM Chief Resident, Maine Medical Center) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Brit Long, MD (@long_brit, EM Chief Resident at SAUSHEC, USAF)

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The dizzy patient is both a common complaint and source of anxiety for the emergency physician. The differential diagnosis is broad and riddled with dangerous pathology. It is further complicated by the fact that patients have a challenging time providing an accurate history regarding this chief complaint, leading to difficulty narrowing down your considerations. Lastly, there are numerous commonly-held false beliefs, leading to controversy and confusion amongst practitioners. This article is meant to simplify the approach to the dizzy patient in a practical manner, focusing on the “can’t miss” diagnoses that fall along this path.

First, many approaches to the workup of the dizzy patient focus on separating your patients into “pre-syncope vs vertigo” before starting your workup. This makes sense since dizziness can describe either of these two entities; however, they are completely different in etiology and require different evaluations. However, as noted above, to the best of their abilities many patients often cannot tell you reliably which of these two entities they are suffering from. Thus instead of starting off by asking the patient to tell you which of these two camps they fall into (ie, asking “Do you feel light-headed or is the room spinning?”), it is often more prudent to allow yourself to make that decision based on the patient’s description of the symptoms and exam. This article will focus primarily on the vertiginous patient due to the large scope of grouping the evaluation of both vertigo and presyncope into one paper.

 

Initial Evaluation

Upon entering the room, as always, check the basics. What does your patient look like? Are they hemodynamically stable? Vital signs (including blood sugar) will often hint towards an etiology of the dizziness. For example, tachycardia, hypotension, hypoxia, or hypoglycemia might point towards pre-syncope (as opposed to vertigo). On the other hand, a patient who cannot even sit upright during the exam due to ataxia or open their eyes during the history due to the spinning sensation and nausea makes vertigo a more likely culprit. Of note, while orthostatic vital signs are often acquired to try to differentiate these two entities, they are nonspecific and present in a large portion of individuals, particularly elderly, regardless of their chief complaint. In addition to a basic survey of the patient and vital signs, consider an EKG and place the patient on the monitor at this time. At this point, consider and treat immediately threatening conditions. These include hypoglycemia, hemorrhage, sepsis, and arrhythmias.

 

History of Present Illness

As emergency physicians, we must continue to first consider the most dangerous and immediately threatening conditions. There are several symptom complexes that can present with dizziness that require immediate consideration. These high-risk symptom complexes and their potential diagnoses include:

Dizziness + Headache/Neck Pain: Subarachnoid hemorrhage, Hemorrhagic stroke, Vertebral artery dissection

Dizziness + Chest pain/Shortness of breath: Acute coronary syndrome, Pulmonary embolism

Dizziness + Palpitations: Arrhythmia

Dizziness + Focal neurologic deficits: Stroke, Ramsay-Hunt syndrome

If the patient denies these symptoms on your initial evaluation, continue with your typical history-taking as you normally would. Pay particular attention to the duration, timing, and triggers of the symptom of dizziness as this is a key part of narrowing the differential diagnosis.

 

Pre-syncope or light-headedness: Dizziness is triggered with upright positioning or walking with little or no symptoms with movement of the head only (eg turning the head back and forth while sitting or lying down). This entity is described as a sensation similar to when one stands up too quickly. A basic history, review of systems, and physical exam will often help the practitioner come to a list of potential etiologies although. The initial differential diagnosis is broad including:

-Poor oral intake

-GI fluid losses (diarrhea, vomiting)

-Hemorrhage/Anemia (GI bleed, ectopic pregnancy, ruptured AAA)

-Neurogenic (vasovagal episode, post-micturition/defecation)

-Arrhythmia

-Metabolic disturbance (hypoglycemia, renal failure, electrolyte disturbance)

-Infection/sepsis

-Medication (any new medications or changed dosages, diuretics, antihypertensives, antiarrhythmics, anticholinergics)

 

The vertiginous syndromes: Dizziness is described as a spinning sensation associated with nausea.

Acute vestibular syndrome: Fairly abrupt in onset, continuous, and often lasts days to weeks. It may improve with time. The differential includes:

-Stroke

 -Vestibular neuronitis

 -Multiple sclerosis

 -Post-traumatic

 

Spontaneous episodic vestibular syndrome: Composed of episodes without any trigger lasting minutes to days. While it may worsen with movement, the sensation of vertigo persists despite complete stillness on the part of the patient. The differential includes:

-Vestibular migraine

-Acute labyrinthitis

-Vestibular neuronitis

 -Meniere’s disease

-Seizures

-Transient ischemic attack

 

Triggered episodic vestibular syndrome: Episodes are triggered by movement in the head or body. Between episodes, the patient is completely asymptomatic. The differential diagnosis is short including:

-Benign paroxysmal vestibular syndrome

 -Orthostasis

 

Chronic vestibular syndrome: Dizziness is described as a spinning sensation associated with nausea. It is gradual in onset, continuous, lasts week or months (or longer), and often worsens with time. The differential includes:

-Intracranial mass (tumor or abscess)

-Drugs/toxins (antiepileptics, aminoglycosides, loop diuretics, salicylates)

-Vestibular neuronitis

 

History of present illness, part II

As previously stated, the majority of this article will focus on the evaluation of the vertiginous patient. The primary concern of the emergency practitioner in this case should be whether or not this may represent a posterior stroke due to the importance of timely diagnosis and treatment of this entity, particularly if the patient is a candidate for thrombolysis. Some aspects of the patient’s description of the vertigo make this more likely.

Risk Category                 History Features

High Risk Factors ·      Gait disturbance (OR 5.9-9.3)1, 3-5, 8, 10

·      Focal neurologic complaints suggesting cerebellar dysfunction (Diplopia, Dysarthria, Dysphagia, Dystaxia, Vertigo)1, 4, 8

Moderate Risk Factors  

·      Sudden onset of symptoms3-6

·      Headache3, 5

 

Low Risk or

Non-predictive Factors

·      Positional symptoms1

·      Isolated vertigo (0.7% risk of CVA)2, 6

·      Auditory symptoms6

 

As noted in the table, positional symptoms have not been shown to be predictive of the risk of stroke. This is a commonly-held misconception: that if dizziness worsens with movement then it is likely to be BPPV. However, all vertigo will worsen with movement, regardless of the cause. BPPV is unique in that while at rest, the patient is completely asymptomatic. This feature does point towards a low risk of stroke, unlike a worsening of symptoms with movement. Additional low-risk factors including auditory symptoms and isolated vertigo (ie lack of other neurologic deficits), both pointing towards a peripheral cause of the symptoms.

In terms of the patient’s medical history, both age greater than 60 and prior stroke have been noted to be moderate risk factors for stroke as a cause of the vertigo.1, 4, 6-11

 

Physical Exam

Once the history-taking is complete, move on to your physical exam. A thorough neurologic exam is a key part of the work-up of the dizzy patient including cerebellar and cranial nerve testing in addition to the basic exam. The HiNTS exam is a set of physical exam maneuvers published in 2009 that can be considered as a part of your neurologic testing as well, especially in the patient with acute vestibular syndrome. These examinations are difficult to describe in a succinct manner, and we would recommend that the reader watches a video demonstration either on YouTube or at (http://emcrit.org/misc/posterior-stroke-video). This exam compromises three specific tests:

1) Head impulse: In this test, the physician is testing the vestibulo-ocular reflex. The patient’s head is thrust quickly from pointing to one side back to center with the patient’s eyes focused on the physician in front of them. In a peripheral lesion (such as Meniere’s disease), this will be abnormal on one side, indicated by a corrective saccade as opposed to the normal smooth eye movements. In a central lesion, there will be no effect of this reflex. This is commonly confusing because an abnormal test indicates a benign pathology whereas a normal test (in the setting of vestibular dysfunction such as vertigo and nystagmus) can indicate central pathology such as a stroke. Of note, this test should only be used in patients with acute vestibular syndrome.

2) Nystagmus: Direction-changing horizontal nystagmus or any vertical or rotatory nystagmus indicates a central lesion, while unidirectional horizontal nystagmus is indicative of a peripheral lesion.

3) Test for Skew: As the patient’s eyes are each covered and uncovered separately while focusing on an object (such as the physician’s nose), they should (in the absence of a central lesion), remain focused on the same spot with no vertical correction. In a central brainstem lesion with an imbalance of vestibular tone, they will deviate in a vertical manner. This test is specific for central pathology, but not sensitive.

Risk Category                       Physical Exam Features

High Risk Features ·      Focal Neuro Deficit (OR 5.9; Sensitivity 64%, Specificity 100%)1, 4, 8

·      Severe Truncal Ataxia (Sensitivity 33%, Specificity 100%)4

·      Normal Head Impulse Test in Setting of Acute Vestibular Syndrome

(+LR 18.3, Sensitivity 85%, Specificity 95%)9, 18

·      Direction-changing, rotatory or vertical nystagmus (Sensitivity 38%, Specificity 92%)18

·      Positive skew deviation (Sensitivity 30%, Specificity 98%)18

·      Abnormal HiNTS (Sensitivity 88-100%, Specificity 85-98%)4, 18-21

Low Risk Features ·      Normal Neurological Exam (-LR 0.49, OR 0.05) 2, 4

·      Abnormal head impulse test (-LR 0.16) 18

·      Normal HiNTS exam (-LR 0-0.03) 4, 19, 20

Non-predictor ·      Dix-Hallpike maneuver (OR 0.0-1.2) 1

 

A recent publication in Journal of Emergency Medicine by Dr. Edlow and Dr. Newman-Toker recommends asking 5 questions in the evaluation of vertigo with acute vestibular syndrome:22

  1. Is the patient unable to sit or stand help?
  2. Does the patient have a focal finding on neurological examination?
  3. Does the patient have worrisome spontaneous or gaze-evoked nystagmus?
  4. Does the patient have negative HIT?
  5. Does the patient have skew deviation (vertical eye misalignment)?

If the answer is yes to any of the above, further evaluation for stroke is recommended.22

Diagnostic Imaging

As the last step in evaluating your dizzy patient, one must consider diagnostic imaging for an acute stroke. Although most providers realize the limited sensitivity of CT scanning for acute stroke, many may not realize how low the sensitivity for acute posterior stroke is with MRI scanning, even within the first 24 hours. In the table below are listed the sensitivities for the various scanning modalities available to use for posterior strokes. As noted, the gold standard at this time is diffusion-weighted imaging on MRI.

MRI DWI ·      Sensitivity within 3 hours (≥41%)13, 16

·      Sensitivity within 24 hours (≥83%)13, 14, 16

·      Up to 23% may be missed in the first 48 hours9, 14, 17

MRI T2 Imaging ·      Sensitivity within 24 hours (40%)15
CTA ·      Sensitivity within 6 hours (26-61%)13, 16
CT Without Contrast ·      Sensitivity within 3 hours (10%)23

·      Sensitivity within 24 hours for posterior CVA (41%)13


Summary

The dizzy patient can be a difficult patient encounter with multiple dangerous diagnoses to consider. While many patients are unable to reliably describe whether they are suffering from presyncope or vertigo (and thus may require an evaluation for both entities), some will provide historical clues or descriptors that will allow a narrowing of the differential at this initial step. As always, immediate life-threatening conditions must be considered such as arrhythmias, hemorrhage, or sepsis. Many of these conditions will be readily apparent on either the initial vital signs (including blood glucose and telemetry/EKG) or with basic labs (such as a CBC and a BMP). If the patient describes true vertigo, a thorough neurologic exam is key and the HiNTS exam (best in the patient with acute vestibular syndrome), while difficult for the inexperienced practitioner, has been shown to have excellent sensitivity and specificity for acute stroke. With practice, one should find him/herself comfortably able to navigate the treacherous waters of the “weak and dizzy” and be able to safely decide on the appropriate disposition of these patients.

 

References / Further Reading:

1) Navi BB, Kamel H, Shah MP, et al. Rate and predictors of serious neurologic causes of dizziness in the emergency department. Mayo Clin Proc. 2012;87(11):1080-8.

2) Kerber KA, Brown DL, Lisabeth LD, Smith MA, Morgenstern LB. Stroke among patients with dizziness, vertigo, and imbalance in the emergency department: a population-based study. Stroke. 2006;37(10):2484-7.

3) Kase CS, Norrving B, Levine SR, et al. Cerebellar infarction. Clinical and anatomic observations in 66 cases. Stroke. 1993;24(1):76-83.

4) Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009;40(11):3504-10.

5) Newman-Toker DE, Kattah JC, Alvernia JE, Wang DZ. Normal head impulse test differentiates acute cerebellar strokes from vestibular neuritis. Neurology. 2008;70(24 Pt 2):2378-85.

6) Gomez CR, Cruz-Flores S, Malkoff MD, Sauer CM, Burch CM. Isolated vertigo as a manifestation of vertebrobasilar ischemia. Neurology. 1996;47(1):94-7.

7) Lee H, Kim BK, Park HJ, Koo JW, Kim JS. Prodromal dizziness in vestibular neuritis: frequency and clinical implication. J Neurol Neurosurg Psychiatr. 2009;80(3):355-6.

8) Chase M, Joyce NR, Carney E, et al. ED patients with vertigo: can we identify clinical factors associated with acute stroke? Am J Emerg Med. 2012;30(4):587-91.

9) Morita S, Suzuki M, Iizuka K. False-negative diffusion-weighted MRI in acute cerebellar stroke. Auris Nasus Larynx. 2011;38(5):577-82.

10) Kerber KA, Zahuranec DB, Brown DL, et al. Stroke risk after nonstroke emergency department dizziness presentations: a population-based cohort study. Ann Neurol. 2014;75(6):899-907.

11) Lee CC, Su YC, Ho HC, et al. Risk of stroke in patients hospitalized for isolated vertigo: a four-year follow-up study. Stroke. 2011;42(1):48-52.

12) Wasay M, Dubey N, Bakshi R. Dizziness and yield of emergency head CT scan: is it cost effective? Emerg Med J. 2005;22(4):312.

13) Fiebach JB, Schellinger PD, Jansen O, et al. CT and diffusion-weighted MR imaging in randomized order: diffusion-weighted imaging results in higher accuracy and lower interrater variability in the diagnosis of hyperacute ischemic stroke. Stroke. 2002;33(9):2206-10.

14) Hwang DY, Silva GS, Furie KL, Greer DM. Comparative sensitivity of computed tomography vs. magnetic resonance imaging for detecting acute posterior fossa infarct. J Emerg Med. 2012;42(5):559-65.

15) Linfante I, Llinas RH, Schlaug G, Chaves C, Warach S, Caplan LR. Diffusion-weighted imaging and National Institutes of Health Stroke Scale in the acute phase of posterior-circulation stroke. Arch Neurol. 2001;58(4):621-8.

16) Chalela JA, Kidwell CS, Nentwich LM, et al. Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison. Lancet. 2007;369(9558):293-8.

17) Morita S, Suzuki M, Iizuka K. False-negative diffusion-weighted MRI in acute cerebellar stroke. Auris Nasus Larynx. 2011;38(5):577-82.

18) Tarnutzer AA, Berkowitz AL, Robinson KA, et al. Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome. CMAJ. 2011 Jun 14;183(9):E571-92.

19) Chen L, Lee W, Chambers BR, et al. Diagnostic accuracy of acute vestibular syndrome at the bedside in a stroke unit. J Neurol. 2011 May;258(5):855-61.

20) Newman-Toker DE, Kerber KA, Hsieh YH, et al. HINTS outperforms ABCD2 to screen for stroke in acute continuous vertigo and dizziness. Acad Emerg Med. 2013 Oct;20(10):986-96.

21) Batuecas-Caletrio A, Yanez-Gonzalez R, Sanchez-Blanco C, et al. Peripheral vertigo versus central vertigo. Application of the HINTS protocol. Rev Neurol. 2014 Oct 16;59(8):349-53.

22) Edlow J and Newman-Toker D. Using the physical examination to diagnose patients with acute dizziness and vertigo. Journ Emerg Med. 2016, in press: http://dx.doi.org/10.1016/j.jemermed.2015.10.040.

23) Chalela JA, Kidwell CS, Nentwich LM, et al. Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison. Lancet. 2007;369(9558):293-8.