A clear and different approach to understanding patients with vertigo

1. A clinical approach to the
diagnosis of vertigo
John Waterston
Alfred Hospital
Melbourne

2. Traditional neurological diagnosis
►Localisation of lesion site
“where”
►Identification of pathology
“what”

3. HOWEVER
The vast majority of cases of vertigo
are due to peripheral causes or
benign central conditions (migraine).

4. Is it vertigo?
► Definition: an illusion of motion
 Spinning, dropping, tilting, falling
 “something moving inside my head”
► Usually aggravated by head movements
► Differential diagnosis large
 Anxiety and hyperventilation
 Postural hypotension

5. Syndrome approach
►Acute, chronic or recurrent
►Spontaneous or (head) motion-
induced

6. 4 key syndromes
►Acute vestibulopathy
►Recurrent vestibulopathy
}
spontaneous
►Motion-induced vertigo
►Disequilibrium

7. 1. Acute vestibulopathy
Vestibular neuritis
Stroke (PICA, AICA)
Perilymph fistula
Trauma

8. Vestibular neuritis (neuronitis)
►A common cause of acute vertigo
► Many cases thought to be due to reactivation of
herpes simplex I
► Similar pathogenesis to Bell’s palsy
► Acute vertigo, unidirectional nystagmus

9. Normal VOR
Abnormal VOR
Halmagyi & Curthoys, 1988.

10. Management:
Shupak et al, Otology & Neurotology. 2008. 29:368-374.
Strupp et al, NEJM. 2004. 351:354-361.
► Prednisolone aids clinical and laboratory recovery
 1 mg/kg for 5 days, followed by reducing dose over
next 15 days.
► Valacyclovirineffective
► Other treatment
 prochlorperazine, promethazine

11. HINTS to Diagnose Stroke in the Acute
Vestibular Syndrome
Three-Step Bedside Oculomotor Examination
More Sensitive Than Early MRI Diffusion-
Weighted Imaging
Jorge C. Kattah, MD; Arun V. Talkad, MD; David Z. Wang, DO;
Yu-Hsiang Hsieh, PhD, MS; David E. Newman-Toker, MD, PhD
Stroke 2009;40;3504-3510

12. HINTS (high stroke risk)
►Head
►Impulse (normal)
►Nystagmus (direction changing)
►Test of
►Skew deviation (present)

14. Benign HINTS examination result at the
bedside “rules out” stroke better than a
negative MRI with DWI in the first 24 to
48 hours after symptom onset
The sensitivity of early MRI with DWI
for lateral medullary or pontine
infarction was lower than that of the
bedside examination (72% versus
100%)

15. 2. Recurrent vestibulopathy
Migraine
Meniere’s disease
Vertebro-basilar insufficiency
Vestibular paroxysmia
Focal epilepsy
Episodic ataxia

16. 3. Motion induced vertigo
Uncompensated peripheral
lesion
Benign positional vertigo
Migraine
Cerebellar disease
Cervical vertigo
Usually respond to physical treatment modalities

17. Benign positional vertigo
► ~25% of cases of vertigo.
► May be primary or secondary.
► Short-lived bouts of vertigo.
► Positional features
 in bed, head extension (“top shelf vertigo”), bending.
► Usually curable!

18. Mechanism of benign positional vertigo

19. Diagnosis
► Must see nystagmus with vertigo
► Patients with other vestibular disorders will often
feel dizzy during the Hallpike manoeuvre
► Spontaneous or central nystagmus may be more
prominent during positional testing

20. Epley manoeuvre (right sided BPV)

21. Semont manoeuvre for right sided BPV

22. Brandt-Daroff exercises for management of benign
positional vertigo (posterior canal)
Acta Otolaryngol. 1980;106:484-485

23. 4. Disequilibrium
► CNS
 cerebellar disease
 normal pressure hydrocephalus
 multi infarct state
► Proprioceptive loss
 spinal disease
 peripheral neuropathy
► Other
 bilateral vestibular hypofunction
 ageing
 hypothyroidism
 multi-sensory dizziness/disequilibrium
(visual, vestibular, cervical spine, neuropathy, orthopaedic)

24. “Red Flags”
► Other neurological signs
► Ataxia out of proportion to vertigo
► Nystagmus out of proportion to vertigo
► Central nystagmus
 vertical, gaze evoked, dissociated, acquired
pendular
► Central eye movement abnormalities
 broken pursuit , gaze palsy, dysmetric or slow
saccades, skew deviation

25. Summary
► Learn to differentiate between spontaneous and
(head) motion induced vertigo
► Think of migraine, particularly in the younger
patient presenting with unexplained recurrent
vertigo.
► Vertebro-basilar ischaemia is a rare diagnosis
► Examine the eye movements carefully
► Do a Hallpike test (except when there is obvious
spontaneous nystagmus).