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BPPV: Identification, Treatment and Differential Diagnosis
1
Presented by
Melissa Koehl, PT, OCS Sept 24, 2015
WHAT WE WILL LEARN
• BPPV has a classic and easy to identify presentation
• 1. episodes of severe spinning vertigo (<1 min) triggered by change in head position
relative to gravity.
• 2. Needs to be confirmed Dix-Hallpike. + if vertigo AND nystagmus <1 min, that has a
latency 5-20 before onset.
• Pt’s that don’t fit the above presentation most likely DON’T have BPPV
• For pts with acute vestibular syndrome (AVS), the oculomotor HINTS
exam is more sensitive than MRI in the 1st 48 hrs to differentiate posterior
CVA from vestibular neuritis
• Dizziness produced with seated neck rotation NOT indicative of BPPV;
likely cervicogenic. Need to consider for VBI, especially if c/o other VBI
symptoms + stroke risk factors or recent neck trauma (even minor!)
2
3
BENIGN PAROXYSMAL POSITIONAL
VERTIGO : OVERVIEW
• THE MOST COMMON FORM OF DIZZINESS
• Most common between ages 60-70 (Batuecas et al, 2013)
• Women 2x more likely (Kollen 2012)
• Lifetime prevelence 2.4% (Von Brevern et al 2007)
• 9% undiagnosed in young adult and older populations (Kerrigan 2013,
Oghalai 2000)
4
INNER EAR ANATOMY
5
6
PATHOPHYSIOLOGY OF BPPV
• Otoconia to become dislodged from the utricle
• Cause unknown and/or degenerative in large majority of cases
• Recent trauma, symptom onset <1week. More common cause for
yougner pt’s
• Posterior canal most commonly affected. 85-95% (Parnes et al
2003)
7
8
BPPV VARIATIONS
• Horizontal Canal: 10-15% (Bhattacharyya et al 2008)
• Subjective symptoms indistinguishable from Posterior Canal BPPV
• Anterior Canal: 3% (Anagnostou et al 2015)
• Multiple canal involvement: RARE
• Bilateral: RARE
• Cupulolisthiasis: RARE
• Otoconia adhered to cupula instead of floating in canal.
9
BPPV SYMPTOMS
KEY COMPLAINT = Brief (< 1 min) and severe episodic
rotatory vertigo related to change in head position relative
to gravity.
In between episodes of vertigo, feel generally ok but may
very mild other symptoms
• Imbalance (49%)
• Fear of falling (36%)
• Nausea (33%)
• Oscillopsia (31%)
• Falls (1%)
10
Von Brevern 2007
BPPV SYMPTOMS
If pt does not describe episodes brief,
severe, spinning vertigo during head
movement relative to gravity =
Pt does NOT have BPPV!
11
BPPV: SYMPTOMS
12
Present during change of head
position relative to gravity.
Vertigo subsides when head
and
Otoliths stop moving < 1 min
Common Complaints:
1. Sit -> laying down
2. Looking up or down
3. Bending over
4. Rolling over in bed
***Symptoms with cervical rotation in sitting/standing NOT common in BPPV.
Need to consider cervicogenic or VBI**
CLARIFICATION
QUESTIONS TO ASK
• Specifically how long does vertigo last?
• May feel nauseated/unwell for longer than 1 min, but true vertigo episode
will be <1 min
• Describe what their vertigo feels like
• If not described as spinning - not BPPV
• Movements or positional changes that trigger the vertigo?
• Do they get vertigo when staying perfectly still?
• If yes - not BPPV
• Presence of tinnitus, aural fullness and hearing loss
(suggests Meiner’s)
13
• https://www.youtube.com/watch?v=Xx5dUvtUGbE
14
TESTING FOR BPPV
• Dix-Hallpike Test: Gold Standard for diagnosis of
posterior/anterior canal BPPV
• 79% sensitivity
• 75% specificity
• +LR 3.17
• -LR 0.28
• Sidelying Test: alternative
• Use when bed does not allow for of 30°extension off the edge, OR
• For pt’s that can’t tolerate Dix-Hallpike due to back pain, neck pain,
limited mobility
•
15
Halker et al 2008
DIX-HALLPIKE TEST
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DIX-HALLPIKE
TEST
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L ear down = testing L posterior canal
R ear down = testing R posterior canal
DIX-HALLPIKE TEST
1. Rotate neck 45° toward side being tested
2. Rapidly lay pt down in 30° extension off edge of bed,
while maintaining 45° rotation
3. Maintain position at least 30-45 sec while observing for
vertigo and nystagmus
1. Slowly return to sitting (sometimes will have reversal of
nystagmus). Dizziness with return to sit not a + finding
2. Repeat on the opposite side
18
SIDELYING TEST ALTERNATIVE TO DIX HALLPIKE
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1. Rotate head 45°
Away from side being
tested
2. Rapidly bring pt
into sidelying while
maintaining 45°
rotation
3. Maintain position
30-45 sec while
observing for vertigo
and nystagmus
4. Slowly return to sit
5. Repeat on
opposite side
SIDELYING TEST
ALTERNATIVE TO DIX-HALLPIKE
20
L sidelying = testing L posterior canal
R sidelying = testing R posterior canal
RIGHT POSTERIOR CANAL BPPV
21
Right Left
Upbeating, right torsional
+latency of onset, duration < 1 min
vertigo same latency and duration as nystagmus
INTERPRETATION OF
NYSTAGMUS
** Posterior canal BPPV = Upbeating/torsional**
• In BPPV, there will always be a vertical AND torsional
component toward the effected side
• R posterior canal BPPV -> upbeating/R torsional
• L posterior canal BPPV -> upbeating/L torsional
• In BPPV, vertigo and nystagmus will fatigue on repeated testing
22
DIAGNOSTIC CRITERIA FOR
POSTERIOR CANAL BPPV
Subjective: repeated episodes of vertigo with changes in head
position relative to gravity
Exam: Dix Hallpike
1. Vertigo with nystagmus (vertical AND torsional)
2. Latency period ( 5-20 sec) prior to onset of vertigo and
nystagmus
3. Vertigo and nystagmus increase then resolve in < 60 sec from
onset of nystagmus
• ALL of the above criteria must be present to definitively make
diagnosis
Bhattacharyya et al 2008
23
TREATMENT =
CANALITH
REPOSITIONING
MANEUVER
EPLEY FOR
POSTERIOR
CANAL
24
EPLEY MANEUVER
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Treatment for L posterior canal shown
Each position should be maintained for
30 sec or longer, after nystagmus and
vertigo resolve
EPLEY MANEUVER
For treatment of Posterior Canal BPPV
1. Start in sitting, head turned 45⁰ toward the effected side.
2. Quickly lay pt supine in 30° extension while maintaining 45°
rotation toward effected side
3. Turn head 90º toward the unaffected ear
4. Turn pt to side lying while still in 45° rotation toward unaffected
ear (pt looking at floor)
5. Return to sitting at edge of bed while maintaining 45° rotation
toward unaffected ear and chin tucked
• Each position should be maintained for 30 sec or longer,
after nystagmus and vertigo resolve
26
PROGNOSIS
• VERY GOOD!
• Meta-analysis: 81% recovery, compared to 37.% in
placebo or untreated subjects (Helminski et al 2010)
• With repeated maneuvers in a single visit or repeated visits,
remission is >90% (Lynn et al 1995)
• 1 year recurrence rate 15% (Von Brevern 2007 )
• Referral to PT beneficial for repeated testing/CRM,
treatment of residual balance deficits, motion sensitivity
27
BPPV CASE
Subjective
• 59 y/o woman, insidious onset vertigo 2-3 wks ago
• Described as spinning vertigo. Intermittent. Lasts < 1 min
• Present when looking up, looking down and especially looking up
and to the R
• Also c/o constant woozy/drunk feeling that is worse when looking
down
• 1 fall down the stairs due to vertigo while looking down
• History of congenital bilat low freq hearing loss, bilat tinnitus
migraine HA (all unchanged since onset of vertigo)
• Occasional neck pain described as tension prior to migraine HA,
not present recently
• Denies other central neurological or VBI symptoms
28
BPPV CASE
• Objective
• Gait wnl, no unsteadiness, ataxia or other gait deviations
• C-spine ROM wnl, no pain or dizziness all directions
• VBI screen neg for dizziness or nystagmus (sustained seated
cervical rotation)
• Occulomotor testing neg for central or peripheral dysfunction
• Dix-Hallpike R: + robust vertigo and up beating/R torsional
nystagmus, latency 2-3 sec, lasted < 1 min
• Dix-Hallpike L: +slight vertigo and up beating/R torsional
nystagmus, latency 2-3 sec, lasted <1 min
• Horizontal Roll Test: neg bilat
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BPPV CASE
Diagnosis = BPPV R posterior canalisthiasis
• Treatment: Epley Manuver for the R ear x 3  less vertigo/nystagmus ea
rep
• Post-Epley instructions. 48 hrs - Avoid sleeping on involved side. Avoid
forceful head movements, sustained non-neutral neck positions (beauty
parlor..)
Reevaluation and d/c: Visit 2
• No more vertigo since initial treatment
• Occasional “woozy” feeling when looking down, but very mild
• Dix Hallpike neg bilat
• Instructed in 1 habituation exercise and 1 VOR retraining to address any
potential mild vestibular hypofunction or motion sensitivity due to 2-3
week presence of BPPV
30
SELF EPLEY FOR DIZZY PATIENTS?
• If clear positive for BPPV on Dix-Hallpike = YES!!
• Epley with clinician preferred, pt’s may have difficulty
doing correctly
• If unclear based on history and Dix-Hallpike = NO!!
• Will not help with other peripheral vestibular d/o
• Potential VA occlusion, cervical nerve root irritation during
maneuver
• Referral to ENT and PT helpful for differential and treatment
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32
SELF EPLEY for Left Posterior canal
Wait 30 sec
after
symptoms
subside in ea
position
Do 3x/day
until symptom
free, before
bed may be
better
tolerated
Avoid sleeping
on effected
side
Should
resolve in <1
week
DIFFERENTIAL
DIAGNOSIS
BPPV is easily
differentiated from all
other forms of dizziness
33
If symptoms and Dix-Hallpike findings do not clearly match
the clinical pattern of BPPV, other diagnoses need to be
investigated!!
DIFFERENTIAL DIAGNOSIS
Vestibular: Most common
• BPPV – 50%.
• Meniere’s Disease - 18%.
• Vestibular Neuritis and Labyrinthitis – 14%.
Non-vestibular
• Central Pathology (tumor, posterior circulation CVA)
• Cardiac
• Psychiatric (anxiety, panic, hyperventilation syndrome)
• Cervicogenic
• Vertiginous migraine
• Medical (orthostatic hypotension, medications)
34
DIFFERENTIAL DIAGNOSIS
• history and detailed oculomotor testing very important to
differential central from peripheral vestibular disorders
35
OCULOMOTOR EXAM
Test CENTRAL PERIPHERAL
Resting Nystagmus* X
Gaze Holding
Nystagmus*
X + if direction
changing
or vertical
X + in vestibular
neuritis,
unidirectional
and horizontal
Smooth Pursuit X + if catch up
saccade
Saccades X + if over/undershoot
VOR cancellation X
Skew Deviation X
Head Thrust/Head
Impulse Test (VOR)
X
Dynamic Visual Acuity X + in vestibular
hypofunction
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*better seen without visual fixation
MENIERE’S DISEASE
• Caused by fluctuating increased endolymphatic fluid in the inner ear
• Discrete episodic attacks with triad of sustained vertigo, fluctuating low
freq hearing loss and tinnitus
• Attacks commonly last 2-4 hours
• Constant vertigo at rest, but can get worse with change in head position
• Aural fullness during episodes
• Will feel off balance during attacks
• Some have drop attacks “crisis of Tumarkin”
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38
Meniere’s Disease
MENIERE’S DISEASE
• Once diagnosed and attacks managed with medications,
salt and caffeine restrictions, PT can be helpful to restore
balance, reduce motion sensitivity, treatment of secondary
BPPV
• PT not helpful when having frequent attacks
39
ACUTE VESTIBULAR
SYNDROME
• Rapid onset of CONSTANT vertigo
• Nausea/vomiting
• Gait unsteadiness – significant
• Head motion intolerance
• Spontaneous nystagmus
• Lasts days to weeks
• Most acute vestibular syndrome pts have vestibular
neuritis, but some may be due to posterior circulation CVA
(Newman-Toker et al 2008)
40
ACUTE VESTIBULAR SYNDROME
• Vestibular neuritis and posterior CVA present very
similarly, both have symptoms of AVS
• Posterior CVA can be difficult to diagnose (Kattah et al, Stroke
2009, Newman-Toker et al Acad Emerg Med 2013)
• Often do not present with typical CVA symptoms
• High false negative rate (20%) with MRI in 1st 24 hrs.
• 25% of acute vestibular syndrome presentations in ED represent
posterior circulation infarcts
41
HINTS EXAM
• Head Impulse Test, Nystagmus, Test of Skew
• Use to differentiate CVA vs. vestibular neuritis in patients
with acute vestibular syndrome
• HINTS evaluation more sensitive than MRI in the first 48
hrs in pts with 1 or more stroke risk factors (Newman-Toker 2013)
42
HEAD IMPULSE TEST
• Test of VOR (Vestibulo-Ocular Reflex).
• Ability maintain gaze fixed while head moving
• Interpretation in pt’s with Acute Vestibular Syndrome
• No catch up saccade= CENTRAL
• (+) catch up saccade = PERIPHERAL
43
HEAD IMPULSE TEST
44
Top = normal, eyes stay forward. Normal in asymptomatic. CENTRAL finding if pt has
Bottom = abnormal, (+) catch up saccade. PERIPHERAL finding.
HEAD IMPULSE TEST
45
Pt with vestibular neuritis
+ catch up saccade to the L.
NYSTAGMUS
• Observe for spontaneous and gaze holding nystagmus
• Have pt maintain R and L gaze without visual fixation
• Frenzel goggles ideal. If unavailable, do not have pt fixate on tip of pen,
look at blank wall, piece of paper
• Interpretation
• CENTRAL (posterior CVA) = Direction changing. Highly
specific!!but low sensitivity when absent
• PERIPHERAL (vestibular neuritis) = Unidirectional.
Horizontal/torsional away from effected side.
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DIRECTION CHANGING NYSTAGMUS
WITH CENTRAL LESION
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TEST OF SKEW WITH
COVER TEST
1. Alternate cover each
eye while fixating
2. Observe for
VERTICAL corrective
saccade
+ CENTRAL finding
48
TEST OF SKEW IN PT WITH
CEREBELLAR CVA
49
HINTS EXAM
REVIEW
• Perform in patients presenting with Acute Vestibular
Syndrome
• Head Impulse
• Nystagmus (spontaneous and gaze holding)
• Test of Skew
50
HINTS EXAM INTERPRETATION FOR
AVS PATIENTS
• CENTRAL
• Head Impulse: NEG (no catch up saccade)
• Nystagmus* DIRECTION CHANGING
• Test of Skew +vertical saccade
• PERIPHERAL
• Head Impulse (+) catch up saccade
• Nystagmus* UNILATERAL
• Test of Skew NEG
*Nystagmus is tested spontaneous and gaze holding bilat
51
PROS AND CONS HINTS EXAM
• Fast, inexpensive and several early studies promising for
improved sensitivity for recognizing early posterior CVA
• Grounded in well-established anatomical and physiological
neuroscience
• Some skill required to interpret findings of oculomotor
tests, inter rater reliability not well studied
• Look forward to improving technology to better assess
Head Impulse test
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HEAD IMPULSE TEST
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Computerized HIT machine to measure the presence of catch up saccade
Can be screened clinically in absence of HIT machine
CERVICOGENIC
DIZZINESS
• Key symptom = dizziness provoked by neck rotation while
sitting or standing. Not gravity dependent
• Many potential causes
• Cervical Spine dysfunction
• VBI (atherosclerosis, dissection or rotational occlusion)
• If VBI symptoms +history or risk factors suggestive of VBI,
further imaging needed. Clinical VBI screen not sensitive
or specific
54
CERVICOGENIC DIZZINESS:
MUSCULOSKELETAL
Diagnosis of Exclusion
• Associated with neck pain
• Dizziness and Nystagmus may be present with seated neck rotation
• No other abnormal oculomotor findings
• Usually not spinning vertigo, often described as lightheaded or
imbalance. Variable duration
• Can feel mildly dizzy “all the time”, that’s worse with some head
movements
• Often can reproduce dizziness with palpation or joint mobility
assessment of upper cervical spine
55
Typical rotational vertebral artery occlusion.
Kwang-Dong Choi et al. Stroke. 2013;44:1817-1824
Copyright © American Heart Association, Inc. All rights reserved.
WHEN TO BE CONCERNED FOR VBI
• VBI symptoms
• Dizziness
• Double vision
• Dysarthria
• Dysphagia
• Drop attacks
• Tinnitus
• Blurred vision
• Fainting
• Nausea/vomiting
57
WHEN TO BE CONCERNED FOR VBI
• VBI symptoms plus history
• of stroke risk factors (ischemia)
• of recent head/neck trauma (dissection)
• Symptoms clearly associated with neck rotation (VA rotational
occlusion)
• Presence of central oculomotor or abnormal CN findings
• Patient reports avoidance of end-range neck positions as
a result of fear, this may be indicative of VBI (Johnson et al
2007)
58
VERTEBRALARTERY
ATHEROSCLEROSIS
• VA stenosis accounts for 20% posterior circulation
ischemic stroke (Gulli 2013)
59
CERVICALARTERIAL DISSECTION
60
WHEN TO BE CONCERNED FOR
CERVICAL DISSECTION?
Transient neurological symptoms:
• Most Common: neck pain, HA, blurred vision, dysarthria, dizziness
• Present 1 month prior to diagnosis of cervical artery dissection.
Recent cervical spine trauma, even MINOR
• Most commonly jerky, abrupt movements into hyperextension or
sidebending
• Strenuous activities
Cardiovascular risk factors not strongly associated with
cervical artery dissection
61
Thomas et al 2015
COMPLICATED VESTIBULAR CASE
• 63 y/o woman
• History of I/M vertigo for 8 years.
• Woke up with constant vertigo and
n/v. Worse w/head rotation to the L
• Meclizine not helping
• PMH: DM, HTN,
• FMH: stroke both parents
• Soc: 1 cigarette/mo
•
62
COMPLICATED VESTIBULAR CASE
• Neuro Admit: 3/14
• “exam non focal except stocking glove pattern sensation loss and
hyporeflexia”
• Head CT, CTA and MRI, chest x-ray and 12 lead ECG all
WNL
• IP PT exam: 3/16
• +L saccade testing repeated overshoot (CENTRAL)
• Impaired coordination with L heel to shin and L foot RAM
• Gait ataxic due to dizziness  issued walker
• D/c’d home with ref for Neuro f/u, ENT, and Vestibular PT
63
COMPLICATED VESTIBULAR CASE
• Next day pt developed L facial droop, returned to ED
• Exam in ED NEG for focal neurological deficits
• MRI of brain negative for acute infarct
• 3 days later: OP PT vestibular eval and Neuro f/u appt
• New onset of diplopia, dysphagia, tinnitus R>L, worsening
frontal HA.
64
COMPLICATED VESTIBULAR CASE
• PT Exam
• + VBI screen bilat (Sustained neck rotation in sitting x 10 sec) with
production of lightheadedness and HA
• CN exam: decr L facial light touch sensation (V) and decreased L
facial strength (VII) , +dizziness/imbalance (VIII)
• Oculomotor
• Head Impulse/Head Thrust: bilat catch up saccade (peripheral? Bilat
atypical)
• Nystagmus: +direction changing with gaze holding (CENTRAL )
• Test of Skew: neg
• Saccadic eye movemement: + overshoot bilat (CENTRAL )
65
COMPLICATED
VESTIBULAR CASE
• Neuro f/u appt found same CN findings
• Additional testing
• 3rd MRI  subacute stroke L PICA territory
• Standard angiogram  50% focal stenosis L VA intracranial
segment, evidence of atherosclerotic disease
• Medical Treatment: aspirin, atorvastatin, strict blood
pressure and glucose control.
66
67
COMPLICATED VESTIBULAR CASE
• Symptoms improved with medical management
• Resumed outpatient PT
• After 7 days, pt had onset of episodic positional vertigo
• Seated head rotation no longer symptomatic
• Oculomotor exam unchanged
• Dix-Hallpike positive for classic BPPV with dizziness and L
torsional upbeating nystagmus/dizziness <30 sec
• Treated with Epley  improved
• Continued PT for balance training until safe and IND for
d/c
68
COMPLICATED VESTIBULAR CASE:
WHAT DID WE LEARN?
• Combination of posterior CVA, later developed BPPV
• Oculomotor may have early cues of CENTRAL pathology
• Pt early report of symptoms with L head rotation
consistent with VBI.
• Both CTA and MRA unable to id VA stenosis intracranial
segment.
69
SUMMARY
If pt fits diagnostic criteria for BPPV, treat with Epley
maneuver. Repeat 2-3x for improved outcomes
BPPV CRITERIA: ALL MUST BE MET FOR DIAGNOSIS
Subjective: BRIEF episodes of spinning vertigo with changes in head position
relative to gravity
Exam: with Dix Hallpike
1. Vertigo with nystagmus (vertical AND torsional)
2. Latency period ( 5-20 sec) prior to onset of vertigo and nystagmus
3. Vertigo and nystagmus increase then resolve in < 60 sec from onset of
nystagmus
70
SUMMARY
• Pt’s that do not present with the classic presentation of BPPV, DO
NOT have BPPV!!
• For pts with acute vestibular syndrome (AVS), the oculomotor HINTS
exam is more sensitive than MRI in the 1st 48 hrs to differentiate
posterior CVA from vestibular neuritis.
• Dizziness produced with seated neck rotation NOT indicative of
BPPV; likely cervicogenic. Need to consider VBI, if c/o other VBI
symptoms + stroke risk factors or recent neck trauma (even minor!)
71
THANK YOU!!
72
HELPFUL REFERENCES
• Dizzy patient overview:
• Huh YE and Kim JS. Beside Evaluation of Dizzy Patients. J Clin Neurol.
2013 Oct; 9(4): 203–213
• BPPV Clinical practice guidelines
• Bhattacharyya, Neil et al. Clinical practice guideline: Benign paroxysmal
positional vertigo. Otolaryngology–Head and Neck Surgery (2008) 139,
S47-S8
• Risk factors for cervical artery disection
• Thomas LC, Rivet DA, Attia JR, Levi C.. Risk Factors and Clinical
Presentation of Cervical Arterial Dissection: Preliminary Results of a
Prospective Case-Control Study J Orthop Sports Phys Ther. 2015 July;
45(7)
73
HELPFUL REFERENCES
• HINTS exam
• 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
• 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;20(10):986-96
74
HELPFUL REFERENCES
• VIDEOS:
https://www.youtube.com/watch?v=FwUAUtm-_fM
Dr. Peter John, Emergency Medicine. A Basic Simplified Approach to
the Dizzy Patient Part 1 and 2. Discusses BPPV vs. AVS and
assessing HINTs to r/o stroke in pt’s with AVS.
• Websites:
http://www.dizziness-and-balance.com/
http://vestibular.org/
75
MORE REFERENCES
• Anagnostou E1, Kouzi I2, Spengos K Diagnosis and Treatment of Anterior-Canal Benign
Paroxysmal Positional Vertigo: A Systematic Review. J Clin Neurol. 2015 Jul;11(3):262-
7.
• Batuecas-Caletrio et al., “Benign paroxysmal positional vertigo in the
elderly,” Gerontology, vol. 59, no. 5, pp. 408–412, 2013
• Bhattacharyya, Neil et al. Clinical practice guideline: Benign paroxysmal positional
vertigo Otolaryngology–Head and Neck Surgery (2008) 139, S47-S8
• Campos-Herrera CR, Scaff M, Yamamoto FI, Conforto AB (December 2008).
"Spontaneous cervical artery dissection: an update on clinical and diagnostic aspects".
Arq Neuropsiquiatr 66 (4): 922–7
• Choi K et al. Stroke. 2013;44:1817-1824
• Gulli G, Marquardt L, Rothwell PM, Markus HS. Stroke risk after posterior circulation
stroke/transient ischemic attack and its relationship to site of vertebrobasilar stenosis
pooled data analysis from prospective studies. Stroke (2013)
• Go G et al. Rotational Vertebral Artery Compression : Bow Hunter's Syndrome. J
Korean Neurosurg Soc. 2013 Sep; 54(3): 243–245.
76
MORE REFERENCES
• Heikkila H. Cervical Vertigo. Chapter 17 in Grieve's modern manual therapy. The
vertebral column. Third edn. Ed Boyling JD, Jull GA, Twomey PLT). Churchill
Livngstone,Edinburgh, 2004
• Helminski JO, Zee DS, Janssen I, Hain TC. (2010). Effectiveness of particle
repositioning maneuvers in the treatment of benign paroxysmal positional vertigo: a
systematic review. Physical Therapy 90(5) 1-16
• Johnson EG, Houle S, Perez A, San Lucas S and Papa D. Relationship between the
Duplex Doppler Ultrasound and a Questionnaire Screening for Positional Tolerance of
the Cervical Spine in Subjects with Suspected Vascular Pathology: A Case Series Pilot
Study. J Man Manip Ther. 2007; 15:225-30
• Kerrigan M.A et al “Prevalence of benign paroxysmal positional vertigo in the young
adult population,” PM and R, vol. 5, no. 9, pp. 778–785, 2013.
• Kim YK, Schulman S (April 2009). "Cervical artery dissection: pathology, epidemiology
and management". Thromb. Res. 123 (6): 810–21
• Kollén L et al , “Benign paroxysmal positional vertigo is a common cause of dizziness
and unsteadiness in a large population of 75-year-olds,” Aging—Clinical and
Experimental Research, vol. 24, no. 4, pp. 317–323, 2012
77
MORE REFERENCES
• Liu H (2012) Presentation and outcome of post-traumatic benign paroxysmal positional
vertigo. Acta Oto-Laryngologica, 132: 803–806
• Loudon JK, Ruhl M, Field E. 1997. Ability to reproduce head position after whiplash
injury. Spine 22(8) 865-868.
• Magnusson et al. Cervical muscle afferents play a dominant role over vestibular
afferents during bilateral vibration of neck muscles. J Vest Res 16(2006) 127-136
• Oghalai, JS et al. Stewart, and H. A. Jenkins, “Unrecognized benign paroxysmal
positional vertigo in elderly patients,” Otolaryngology—Head and Neck Surgery, vol.
122, no. 5, pp. 630–634, 2000
• Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal
positional vertigo (BPPV). CMAJ 2003;169:681–93
• Strupp M, Planck JH, Arbusow V, Steiger HJ, Brückmann H, Brandt T. Rotational
vertebral artery occlusion syndrome with vertigo due to “labyrinthine excitation”.
Neurology. 2000;54:1376–1379.
78
MORE REFERENCES
• Tarnutzer AA, Berkowitz AL, Robinson KA, Hsieh YH, Newman-Toker DE. Does my
dizzy patient have a stroke? A systematic review of bedside diagnosis inacute
vestibular syndrome. CMAJ. 2011; 183:E571–92.
• Von Brevern M, Radtke A, Lezius F, et al. Epidemiology of benign paroxysmal
positionalvertigo: a population based study. J Neurol Neurosurg Psychiatry
2007;78:710–715
79
ROLL TEST FOR HORIZONTAL
CANAL
80
ROLL TEST FOR
HORIZONTAL CANAL
1. Begin supine in 30° flexion
2. Quickly rotate head about 90° to one side
3. Return to neutral slowly
3. Quickly rotated head about 90° to the other side
Maintain rotation 1-2 min in each position looking for
dizziness and nystagmus
81
HORIZONTAL
ROLL TEST
82
L ear down = testing L horizontal canal
R ear down = testing R horizontal canal
ROLL TEST: HORIZONTAL CANAL
BPPV FINDINGS
• Same diagnosis criteria as Posterior Canal BPPV
• Brief episodic vertigo with change in head position relative to gravity
• Vertigo associated with nystagmus with horizontal roll test
• Latency prior to onset of vertigo/nystagmus
• Vertigo/nystagmus resolves <60 sec
• Vertigo/nystagmus commonly present in both L and R test
positions
• Effected side more symptomatic
• Nystagmus is horizontal
• Geotropic = toward the ground. (Most common)
• Ageotropic = away from the ground
83
84
HORIZONTAL CANAL BPPV:
SUPINE ROLL TEST
85
R L
R horizontal nystagmus in R rotation
L horizontal nystagmus in L rotation
= Geotropic
“SUBJECTIVE” BPPV
• Vertigo but no nystagmus during Dix-Hallpike
• Same latency, duration of symptoms during Dix-Hallpike
as “objective” BPPV
• All other subjective symptoms will be the same as typical
BPPV, but intensity of vertigo may be less severe
• Responds well to canalith repositioning such as Epley
Maneuver (Hubner et al 2013)
• Hypotheses
• resolving BPPV with only a small amount of ootoliths in the canal
(Alverenga et al. 2011)
• Chronic canalothiasis within the short arm of posterior canal (Büki et
al. 2011)
86
WHEN SYMPTOMS/FINDINGS
CONCERNING FOR VBI
• Refer to physician to consider arterial imaging
• CTA highest sensitivity (100%) vs. MRA (77%). (Systemic Review,
Gottesman 2012)
• Angiogram may be needed for intracranial VA segment
• In the rare case of suspected VA rotational occlusion (bow hunters
syndrome), angiogram in rotation most sensitive (Goo et al 2013)
87
BPPV VS. VBI
• BPPV will not have additional neuro symptoms, central
ocuolmotor findings or other abnormal neurological
findings
• Dix-Hallpike Testing will not fit typical BPPV pattern in VBI
• VBI symptoms during Dix-Hallpike will not resolve in <1
min, will not fatigue with repeated testing and will have
central nystagmus patterns (downbeating, pure vertical or
direction changing)
88
MUSCULOSKELTAL CERVICAL
DIZZINESS VS VBI
• Presence of VBI symptoms + history of stroke risk factors
or recent head/neck trauma (even minor!) = imaging is
needed!!
• If low suspicion of VBI + findings of c-spine dysfunction, a
trial of gentle manual therapy to c-spine will very likely
reduce symptoms of dizziness/nystagmus with immediate
re-test of cervical rotation
89
90
HINTS TESTING IN
PT WITH VESTIBULAR NEURITIS
91

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Bppv final -grand rounds sept 2015

  • 1. BPPV: Identification, Treatment and Differential Diagnosis 1 Presented by Melissa Koehl, PT, OCS Sept 24, 2015
  • 2. WHAT WE WILL LEARN • BPPV has a classic and easy to identify presentation • 1. episodes of severe spinning vertigo (<1 min) triggered by change in head position relative to gravity. • 2. Needs to be confirmed Dix-Hallpike. + if vertigo AND nystagmus <1 min, that has a latency 5-20 before onset. • Pt’s that don’t fit the above presentation most likely DON’T have BPPV • For pts with acute vestibular syndrome (AVS), the oculomotor HINTS exam is more sensitive than MRI in the 1st 48 hrs to differentiate posterior CVA from vestibular neuritis • Dizziness produced with seated neck rotation NOT indicative of BPPV; likely cervicogenic. Need to consider for VBI, especially if c/o other VBI symptoms + stroke risk factors or recent neck trauma (even minor!) 2
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  • 4. BENIGN PAROXYSMAL POSITIONAL VERTIGO : OVERVIEW • THE MOST COMMON FORM OF DIZZINESS • Most common between ages 60-70 (Batuecas et al, 2013) • Women 2x more likely (Kollen 2012) • Lifetime prevelence 2.4% (Von Brevern et al 2007) • 9% undiagnosed in young adult and older populations (Kerrigan 2013, Oghalai 2000) 4
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  • 7. PATHOPHYSIOLOGY OF BPPV • Otoconia to become dislodged from the utricle • Cause unknown and/or degenerative in large majority of cases • Recent trauma, symptom onset <1week. More common cause for yougner pt’s • Posterior canal most commonly affected. 85-95% (Parnes et al 2003) 7
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  • 9. BPPV VARIATIONS • Horizontal Canal: 10-15% (Bhattacharyya et al 2008) • Subjective symptoms indistinguishable from Posterior Canal BPPV • Anterior Canal: 3% (Anagnostou et al 2015) • Multiple canal involvement: RARE • Bilateral: RARE • Cupulolisthiasis: RARE • Otoconia adhered to cupula instead of floating in canal. 9
  • 10. BPPV SYMPTOMS KEY COMPLAINT = Brief (< 1 min) and severe episodic rotatory vertigo related to change in head position relative to gravity. In between episodes of vertigo, feel generally ok but may very mild other symptoms • Imbalance (49%) • Fear of falling (36%) • Nausea (33%) • Oscillopsia (31%) • Falls (1%) 10 Von Brevern 2007
  • 11. BPPV SYMPTOMS If pt does not describe episodes brief, severe, spinning vertigo during head movement relative to gravity = Pt does NOT have BPPV! 11
  • 12. BPPV: SYMPTOMS 12 Present during change of head position relative to gravity. Vertigo subsides when head and Otoliths stop moving < 1 min Common Complaints: 1. Sit -> laying down 2. Looking up or down 3. Bending over 4. Rolling over in bed ***Symptoms with cervical rotation in sitting/standing NOT common in BPPV. Need to consider cervicogenic or VBI**
  • 13. CLARIFICATION QUESTIONS TO ASK • Specifically how long does vertigo last? • May feel nauseated/unwell for longer than 1 min, but true vertigo episode will be <1 min • Describe what their vertigo feels like • If not described as spinning - not BPPV • Movements or positional changes that trigger the vertigo? • Do they get vertigo when staying perfectly still? • If yes - not BPPV • Presence of tinnitus, aural fullness and hearing loss (suggests Meiner’s) 13
  • 15. TESTING FOR BPPV • Dix-Hallpike Test: Gold Standard for diagnosis of posterior/anterior canal BPPV • 79% sensitivity • 75% specificity • +LR 3.17 • -LR 0.28 • Sidelying Test: alternative • Use when bed does not allow for of 30°extension off the edge, OR • For pt’s that can’t tolerate Dix-Hallpike due to back pain, neck pain, limited mobility • 15 Halker et al 2008
  • 17. DIX-HALLPIKE TEST 17 L ear down = testing L posterior canal R ear down = testing R posterior canal
  • 18. DIX-HALLPIKE TEST 1. Rotate neck 45° toward side being tested 2. Rapidly lay pt down in 30° extension off edge of bed, while maintaining 45° rotation 3. Maintain position at least 30-45 sec while observing for vertigo and nystagmus 1. Slowly return to sitting (sometimes will have reversal of nystagmus). Dizziness with return to sit not a + finding 2. Repeat on the opposite side 18
  • 19. SIDELYING TEST ALTERNATIVE TO DIX HALLPIKE 19 1. Rotate head 45° Away from side being tested 2. Rapidly bring pt into sidelying while maintaining 45° rotation 3. Maintain position 30-45 sec while observing for vertigo and nystagmus 4. Slowly return to sit 5. Repeat on opposite side
  • 20. SIDELYING TEST ALTERNATIVE TO DIX-HALLPIKE 20 L sidelying = testing L posterior canal R sidelying = testing R posterior canal
  • 21. RIGHT POSTERIOR CANAL BPPV 21 Right Left Upbeating, right torsional +latency of onset, duration < 1 min vertigo same latency and duration as nystagmus
  • 22. INTERPRETATION OF NYSTAGMUS ** Posterior canal BPPV = Upbeating/torsional** • In BPPV, there will always be a vertical AND torsional component toward the effected side • R posterior canal BPPV -> upbeating/R torsional • L posterior canal BPPV -> upbeating/L torsional • In BPPV, vertigo and nystagmus will fatigue on repeated testing 22
  • 23. DIAGNOSTIC CRITERIA FOR POSTERIOR CANAL BPPV Subjective: repeated episodes of vertigo with changes in head position relative to gravity Exam: Dix Hallpike 1. Vertigo with nystagmus (vertical AND torsional) 2. Latency period ( 5-20 sec) prior to onset of vertigo and nystagmus 3. Vertigo and nystagmus increase then resolve in < 60 sec from onset of nystagmus • ALL of the above criteria must be present to definitively make diagnosis Bhattacharyya et al 2008 23
  • 25. EPLEY MANEUVER 25 Treatment for L posterior canal shown Each position should be maintained for 30 sec or longer, after nystagmus and vertigo resolve
  • 26. EPLEY MANEUVER For treatment of Posterior Canal BPPV 1. Start in sitting, head turned 45⁰ toward the effected side. 2. Quickly lay pt supine in 30° extension while maintaining 45° rotation toward effected side 3. Turn head 90º toward the unaffected ear 4. Turn pt to side lying while still in 45° rotation toward unaffected ear (pt looking at floor) 5. Return to sitting at edge of bed while maintaining 45° rotation toward unaffected ear and chin tucked • Each position should be maintained for 30 sec or longer, after nystagmus and vertigo resolve 26
  • 27. PROGNOSIS • VERY GOOD! • Meta-analysis: 81% recovery, compared to 37.% in placebo or untreated subjects (Helminski et al 2010) • With repeated maneuvers in a single visit or repeated visits, remission is >90% (Lynn et al 1995) • 1 year recurrence rate 15% (Von Brevern 2007 ) • Referral to PT beneficial for repeated testing/CRM, treatment of residual balance deficits, motion sensitivity 27
  • 28. BPPV CASE Subjective • 59 y/o woman, insidious onset vertigo 2-3 wks ago • Described as spinning vertigo. Intermittent. Lasts < 1 min • Present when looking up, looking down and especially looking up and to the R • Also c/o constant woozy/drunk feeling that is worse when looking down • 1 fall down the stairs due to vertigo while looking down • History of congenital bilat low freq hearing loss, bilat tinnitus migraine HA (all unchanged since onset of vertigo) • Occasional neck pain described as tension prior to migraine HA, not present recently • Denies other central neurological or VBI symptoms 28
  • 29. BPPV CASE • Objective • Gait wnl, no unsteadiness, ataxia or other gait deviations • C-spine ROM wnl, no pain or dizziness all directions • VBI screen neg for dizziness or nystagmus (sustained seated cervical rotation) • Occulomotor testing neg for central or peripheral dysfunction • Dix-Hallpike R: + robust vertigo and up beating/R torsional nystagmus, latency 2-3 sec, lasted < 1 min • Dix-Hallpike L: +slight vertigo and up beating/R torsional nystagmus, latency 2-3 sec, lasted <1 min • Horizontal Roll Test: neg bilat 29
  • 30. BPPV CASE Diagnosis = BPPV R posterior canalisthiasis • Treatment: Epley Manuver for the R ear x 3  less vertigo/nystagmus ea rep • Post-Epley instructions. 48 hrs - Avoid sleeping on involved side. Avoid forceful head movements, sustained non-neutral neck positions (beauty parlor..) Reevaluation and d/c: Visit 2 • No more vertigo since initial treatment • Occasional “woozy” feeling when looking down, but very mild • Dix Hallpike neg bilat • Instructed in 1 habituation exercise and 1 VOR retraining to address any potential mild vestibular hypofunction or motion sensitivity due to 2-3 week presence of BPPV 30
  • 31. SELF EPLEY FOR DIZZY PATIENTS? • If clear positive for BPPV on Dix-Hallpike = YES!! • Epley with clinician preferred, pt’s may have difficulty doing correctly • If unclear based on history and Dix-Hallpike = NO!! • Will not help with other peripheral vestibular d/o • Potential VA occlusion, cervical nerve root irritation during maneuver • Referral to ENT and PT helpful for differential and treatment 31
  • 32. 32 SELF EPLEY for Left Posterior canal Wait 30 sec after symptoms subside in ea position Do 3x/day until symptom free, before bed may be better tolerated Avoid sleeping on effected side Should resolve in <1 week
  • 33. DIFFERENTIAL DIAGNOSIS BPPV is easily differentiated from all other forms of dizziness 33 If symptoms and Dix-Hallpike findings do not clearly match the clinical pattern of BPPV, other diagnoses need to be investigated!!
  • 34. DIFFERENTIAL DIAGNOSIS Vestibular: Most common • BPPV – 50%. • Meniere’s Disease - 18%. • Vestibular Neuritis and Labyrinthitis – 14%. Non-vestibular • Central Pathology (tumor, posterior circulation CVA) • Cardiac • Psychiatric (anxiety, panic, hyperventilation syndrome) • Cervicogenic • Vertiginous migraine • Medical (orthostatic hypotension, medications) 34
  • 35. DIFFERENTIAL DIAGNOSIS • history and detailed oculomotor testing very important to differential central from peripheral vestibular disorders 35
  • 36. OCULOMOTOR EXAM Test CENTRAL PERIPHERAL Resting Nystagmus* X Gaze Holding Nystagmus* X + if direction changing or vertical X + in vestibular neuritis, unidirectional and horizontal Smooth Pursuit X + if catch up saccade Saccades X + if over/undershoot VOR cancellation X Skew Deviation X Head Thrust/Head Impulse Test (VOR) X Dynamic Visual Acuity X + in vestibular hypofunction 36 *better seen without visual fixation
  • 37. MENIERE’S DISEASE • Caused by fluctuating increased endolymphatic fluid in the inner ear • Discrete episodic attacks with triad of sustained vertigo, fluctuating low freq hearing loss and tinnitus • Attacks commonly last 2-4 hours • Constant vertigo at rest, but can get worse with change in head position • Aural fullness during episodes • Will feel off balance during attacks • Some have drop attacks “crisis of Tumarkin” 37
  • 39. MENIERE’S DISEASE • Once diagnosed and attacks managed with medications, salt and caffeine restrictions, PT can be helpful to restore balance, reduce motion sensitivity, treatment of secondary BPPV • PT not helpful when having frequent attacks 39
  • 40. ACUTE VESTIBULAR SYNDROME • Rapid onset of CONSTANT vertigo • Nausea/vomiting • Gait unsteadiness – significant • Head motion intolerance • Spontaneous nystagmus • Lasts days to weeks • Most acute vestibular syndrome pts have vestibular neuritis, but some may be due to posterior circulation CVA (Newman-Toker et al 2008) 40
  • 41. ACUTE VESTIBULAR SYNDROME • Vestibular neuritis and posterior CVA present very similarly, both have symptoms of AVS • Posterior CVA can be difficult to diagnose (Kattah et al, Stroke 2009, Newman-Toker et al Acad Emerg Med 2013) • Often do not present with typical CVA symptoms • High false negative rate (20%) with MRI in 1st 24 hrs. • 25% of acute vestibular syndrome presentations in ED represent posterior circulation infarcts 41
  • 42. HINTS EXAM • Head Impulse Test, Nystagmus, Test of Skew • Use to differentiate CVA vs. vestibular neuritis in patients with acute vestibular syndrome • HINTS evaluation more sensitive than MRI in the first 48 hrs in pts with 1 or more stroke risk factors (Newman-Toker 2013) 42
  • 43. HEAD IMPULSE TEST • Test of VOR (Vestibulo-Ocular Reflex). • Ability maintain gaze fixed while head moving • Interpretation in pt’s with Acute Vestibular Syndrome • No catch up saccade= CENTRAL • (+) catch up saccade = PERIPHERAL 43
  • 44. HEAD IMPULSE TEST 44 Top = normal, eyes stay forward. Normal in asymptomatic. CENTRAL finding if pt has Bottom = abnormal, (+) catch up saccade. PERIPHERAL finding.
  • 45. HEAD IMPULSE TEST 45 Pt with vestibular neuritis + catch up saccade to the L.
  • 46. NYSTAGMUS • Observe for spontaneous and gaze holding nystagmus • Have pt maintain R and L gaze without visual fixation • Frenzel goggles ideal. If unavailable, do not have pt fixate on tip of pen, look at blank wall, piece of paper • Interpretation • CENTRAL (posterior CVA) = Direction changing. Highly specific!!but low sensitivity when absent • PERIPHERAL (vestibular neuritis) = Unidirectional. Horizontal/torsional away from effected side. 46
  • 48. TEST OF SKEW WITH COVER TEST 1. Alternate cover each eye while fixating 2. Observe for VERTICAL corrective saccade + CENTRAL finding 48
  • 49. TEST OF SKEW IN PT WITH CEREBELLAR CVA 49
  • 50. HINTS EXAM REVIEW • Perform in patients presenting with Acute Vestibular Syndrome • Head Impulse • Nystagmus (spontaneous and gaze holding) • Test of Skew 50
  • 51. HINTS EXAM INTERPRETATION FOR AVS PATIENTS • CENTRAL • Head Impulse: NEG (no catch up saccade) • Nystagmus* DIRECTION CHANGING • Test of Skew +vertical saccade • PERIPHERAL • Head Impulse (+) catch up saccade • Nystagmus* UNILATERAL • Test of Skew NEG *Nystagmus is tested spontaneous and gaze holding bilat 51
  • 52. PROS AND CONS HINTS EXAM • Fast, inexpensive and several early studies promising for improved sensitivity for recognizing early posterior CVA • Grounded in well-established anatomical and physiological neuroscience • Some skill required to interpret findings of oculomotor tests, inter rater reliability not well studied • Look forward to improving technology to better assess Head Impulse test 52
  • 53. HEAD IMPULSE TEST 53 Computerized HIT machine to measure the presence of catch up saccade Can be screened clinically in absence of HIT machine
  • 54. CERVICOGENIC DIZZINESS • Key symptom = dizziness provoked by neck rotation while sitting or standing. Not gravity dependent • Many potential causes • Cervical Spine dysfunction • VBI (atherosclerosis, dissection or rotational occlusion) • If VBI symptoms +history or risk factors suggestive of VBI, further imaging needed. Clinical VBI screen not sensitive or specific 54
  • 55. CERVICOGENIC DIZZINESS: MUSCULOSKELETAL Diagnosis of Exclusion • Associated with neck pain • Dizziness and Nystagmus may be present with seated neck rotation • No other abnormal oculomotor findings • Usually not spinning vertigo, often described as lightheaded or imbalance. Variable duration • Can feel mildly dizzy “all the time”, that’s worse with some head movements • Often can reproduce dizziness with palpation or joint mobility assessment of upper cervical spine 55
  • 56. Typical rotational vertebral artery occlusion. Kwang-Dong Choi et al. Stroke. 2013;44:1817-1824 Copyright © American Heart Association, Inc. All rights reserved.
  • 57. WHEN TO BE CONCERNED FOR VBI • VBI symptoms • Dizziness • Double vision • Dysarthria • Dysphagia • Drop attacks • Tinnitus • Blurred vision • Fainting • Nausea/vomiting 57
  • 58. WHEN TO BE CONCERNED FOR VBI • VBI symptoms plus history • of stroke risk factors (ischemia) • of recent head/neck trauma (dissection) • Symptoms clearly associated with neck rotation (VA rotational occlusion) • Presence of central oculomotor or abnormal CN findings • Patient reports avoidance of end-range neck positions as a result of fear, this may be indicative of VBI (Johnson et al 2007) 58
  • 59. VERTEBRALARTERY ATHEROSCLEROSIS • VA stenosis accounts for 20% posterior circulation ischemic stroke (Gulli 2013) 59
  • 61. WHEN TO BE CONCERNED FOR CERVICAL DISSECTION? Transient neurological symptoms: • Most Common: neck pain, HA, blurred vision, dysarthria, dizziness • Present 1 month prior to diagnosis of cervical artery dissection. Recent cervical spine trauma, even MINOR • Most commonly jerky, abrupt movements into hyperextension or sidebending • Strenuous activities Cardiovascular risk factors not strongly associated with cervical artery dissection 61 Thomas et al 2015
  • 62. COMPLICATED VESTIBULAR CASE • 63 y/o woman • History of I/M vertigo for 8 years. • Woke up with constant vertigo and n/v. Worse w/head rotation to the L • Meclizine not helping • PMH: DM, HTN, • FMH: stroke both parents • Soc: 1 cigarette/mo • 62
  • 63. COMPLICATED VESTIBULAR CASE • Neuro Admit: 3/14 • “exam non focal except stocking glove pattern sensation loss and hyporeflexia” • Head CT, CTA and MRI, chest x-ray and 12 lead ECG all WNL • IP PT exam: 3/16 • +L saccade testing repeated overshoot (CENTRAL) • Impaired coordination with L heel to shin and L foot RAM • Gait ataxic due to dizziness  issued walker • D/c’d home with ref for Neuro f/u, ENT, and Vestibular PT 63
  • 64. COMPLICATED VESTIBULAR CASE • Next day pt developed L facial droop, returned to ED • Exam in ED NEG for focal neurological deficits • MRI of brain negative for acute infarct • 3 days later: OP PT vestibular eval and Neuro f/u appt • New onset of diplopia, dysphagia, tinnitus R>L, worsening frontal HA. 64
  • 65. COMPLICATED VESTIBULAR CASE • PT Exam • + VBI screen bilat (Sustained neck rotation in sitting x 10 sec) with production of lightheadedness and HA • CN exam: decr L facial light touch sensation (V) and decreased L facial strength (VII) , +dizziness/imbalance (VIII) • Oculomotor • Head Impulse/Head Thrust: bilat catch up saccade (peripheral? Bilat atypical) • Nystagmus: +direction changing with gaze holding (CENTRAL ) • Test of Skew: neg • Saccadic eye movemement: + overshoot bilat (CENTRAL ) 65
  • 66. COMPLICATED VESTIBULAR CASE • Neuro f/u appt found same CN findings • Additional testing • 3rd MRI  subacute stroke L PICA territory • Standard angiogram  50% focal stenosis L VA intracranial segment, evidence of atherosclerotic disease • Medical Treatment: aspirin, atorvastatin, strict blood pressure and glucose control. 66
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  • 68. COMPLICATED VESTIBULAR CASE • Symptoms improved with medical management • Resumed outpatient PT • After 7 days, pt had onset of episodic positional vertigo • Seated head rotation no longer symptomatic • Oculomotor exam unchanged • Dix-Hallpike positive for classic BPPV with dizziness and L torsional upbeating nystagmus/dizziness <30 sec • Treated with Epley  improved • Continued PT for balance training until safe and IND for d/c 68
  • 69. COMPLICATED VESTIBULAR CASE: WHAT DID WE LEARN? • Combination of posterior CVA, later developed BPPV • Oculomotor may have early cues of CENTRAL pathology • Pt early report of symptoms with L head rotation consistent with VBI. • Both CTA and MRA unable to id VA stenosis intracranial segment. 69
  • 70. SUMMARY If pt fits diagnostic criteria for BPPV, treat with Epley maneuver. Repeat 2-3x for improved outcomes BPPV CRITERIA: ALL MUST BE MET FOR DIAGNOSIS Subjective: BRIEF episodes of spinning vertigo with changes in head position relative to gravity Exam: with Dix Hallpike 1. Vertigo with nystagmus (vertical AND torsional) 2. Latency period ( 5-20 sec) prior to onset of vertigo and nystagmus 3. Vertigo and nystagmus increase then resolve in < 60 sec from onset of nystagmus 70
  • 71. SUMMARY • Pt’s that do not present with the classic presentation of BPPV, DO NOT have BPPV!! • For pts with acute vestibular syndrome (AVS), the oculomotor HINTS exam is more sensitive than MRI in the 1st 48 hrs to differentiate posterior CVA from vestibular neuritis. • Dizziness produced with seated neck rotation NOT indicative of BPPV; likely cervicogenic. Need to consider VBI, if c/o other VBI symptoms + stroke risk factors or recent neck trauma (even minor!) 71
  • 73. HELPFUL REFERENCES • Dizzy patient overview: • Huh YE and Kim JS. Beside Evaluation of Dizzy Patients. J Clin Neurol. 2013 Oct; 9(4): 203–213 • BPPV Clinical practice guidelines • Bhattacharyya, Neil et al. Clinical practice guideline: Benign paroxysmal positional vertigo. Otolaryngology–Head and Neck Surgery (2008) 139, S47-S8 • Risk factors for cervical artery disection • Thomas LC, Rivet DA, Attia JR, Levi C.. Risk Factors and Clinical Presentation of Cervical Arterial Dissection: Preliminary Results of a Prospective Case-Control Study J Orthop Sports Phys Ther. 2015 July; 45(7) 73
  • 74. HELPFUL REFERENCES • HINTS exam • 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 • 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;20(10):986-96 74
  • 75. HELPFUL REFERENCES • VIDEOS: https://www.youtube.com/watch?v=FwUAUtm-_fM Dr. Peter John, Emergency Medicine. A Basic Simplified Approach to the Dizzy Patient Part 1 and 2. Discusses BPPV vs. AVS and assessing HINTs to r/o stroke in pt’s with AVS. • Websites: http://www.dizziness-and-balance.com/ http://vestibular.org/ 75
  • 76. MORE REFERENCES • Anagnostou E1, Kouzi I2, Spengos K Diagnosis and Treatment of Anterior-Canal Benign Paroxysmal Positional Vertigo: A Systematic Review. J Clin Neurol. 2015 Jul;11(3):262- 7. • Batuecas-Caletrio et al., “Benign paroxysmal positional vertigo in the elderly,” Gerontology, vol. 59, no. 5, pp. 408–412, 2013 • Bhattacharyya, Neil et al. Clinical practice guideline: Benign paroxysmal positional vertigo Otolaryngology–Head and Neck Surgery (2008) 139, S47-S8 • Campos-Herrera CR, Scaff M, Yamamoto FI, Conforto AB (December 2008). "Spontaneous cervical artery dissection: an update on clinical and diagnostic aspects". Arq Neuropsiquiatr 66 (4): 922–7 • Choi K et al. Stroke. 2013;44:1817-1824 • Gulli G, Marquardt L, Rothwell PM, Markus HS. Stroke risk after posterior circulation stroke/transient ischemic attack and its relationship to site of vertebrobasilar stenosis pooled data analysis from prospective studies. Stroke (2013) • Go G et al. Rotational Vertebral Artery Compression : Bow Hunter's Syndrome. J Korean Neurosurg Soc. 2013 Sep; 54(3): 243–245. 76
  • 77. MORE REFERENCES • Heikkila H. Cervical Vertigo. Chapter 17 in Grieve's modern manual therapy. The vertebral column. Third edn. Ed Boyling JD, Jull GA, Twomey PLT). Churchill Livngstone,Edinburgh, 2004 • Helminski JO, Zee DS, Janssen I, Hain TC. (2010). Effectiveness of particle repositioning maneuvers in the treatment of benign paroxysmal positional vertigo: a systematic review. Physical Therapy 90(5) 1-16 • Johnson EG, Houle S, Perez A, San Lucas S and Papa D. Relationship between the Duplex Doppler Ultrasound and a Questionnaire Screening for Positional Tolerance of the Cervical Spine in Subjects with Suspected Vascular Pathology: A Case Series Pilot Study. J Man Manip Ther. 2007; 15:225-30 • Kerrigan M.A et al “Prevalence of benign paroxysmal positional vertigo in the young adult population,” PM and R, vol. 5, no. 9, pp. 778–785, 2013. • Kim YK, Schulman S (April 2009). "Cervical artery dissection: pathology, epidemiology and management". Thromb. Res. 123 (6): 810–21 • Kollén L et al , “Benign paroxysmal positional vertigo is a common cause of dizziness and unsteadiness in a large population of 75-year-olds,” Aging—Clinical and Experimental Research, vol. 24, no. 4, pp. 317–323, 2012 77
  • 78. MORE REFERENCES • Liu H (2012) Presentation and outcome of post-traumatic benign paroxysmal positional vertigo. Acta Oto-Laryngologica, 132: 803–806 • Loudon JK, Ruhl M, Field E. 1997. Ability to reproduce head position after whiplash injury. Spine 22(8) 865-868. • Magnusson et al. Cervical muscle afferents play a dominant role over vestibular afferents during bilateral vibration of neck muscles. J Vest Res 16(2006) 127-136 • Oghalai, JS et al. Stewart, and H. A. Jenkins, “Unrecognized benign paroxysmal positional vertigo in elderly patients,” Otolaryngology—Head and Neck Surgery, vol. 122, no. 5, pp. 630–634, 2000 • Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ 2003;169:681–93 • Strupp M, Planck JH, Arbusow V, Steiger HJ, Brückmann H, Brandt T. Rotational vertebral artery occlusion syndrome with vertigo due to “labyrinthine excitation”. Neurology. 2000;54:1376–1379. 78
  • 79. MORE REFERENCES • Tarnutzer AA, Berkowitz AL, Robinson KA, Hsieh YH, Newman-Toker DE. Does my dizzy patient have a stroke? A systematic review of bedside diagnosis inacute vestibular syndrome. CMAJ. 2011; 183:E571–92. • Von Brevern M, Radtke A, Lezius F, et al. Epidemiology of benign paroxysmal positionalvertigo: a population based study. J Neurol Neurosurg Psychiatry 2007;78:710–715 79
  • 80. ROLL TEST FOR HORIZONTAL CANAL 80
  • 81. ROLL TEST FOR HORIZONTAL CANAL 1. Begin supine in 30° flexion 2. Quickly rotate head about 90° to one side 3. Return to neutral slowly 3. Quickly rotated head about 90° to the other side Maintain rotation 1-2 min in each position looking for dizziness and nystagmus 81
  • 82. HORIZONTAL ROLL TEST 82 L ear down = testing L horizontal canal R ear down = testing R horizontal canal
  • 83. ROLL TEST: HORIZONTAL CANAL BPPV FINDINGS • Same diagnosis criteria as Posterior Canal BPPV • Brief episodic vertigo with change in head position relative to gravity • Vertigo associated with nystagmus with horizontal roll test • Latency prior to onset of vertigo/nystagmus • Vertigo/nystagmus resolves <60 sec • Vertigo/nystagmus commonly present in both L and R test positions • Effected side more symptomatic • Nystagmus is horizontal • Geotropic = toward the ground. (Most common) • Ageotropic = away from the ground 83
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  • 85. HORIZONTAL CANAL BPPV: SUPINE ROLL TEST 85 R L R horizontal nystagmus in R rotation L horizontal nystagmus in L rotation = Geotropic
  • 86. “SUBJECTIVE” BPPV • Vertigo but no nystagmus during Dix-Hallpike • Same latency, duration of symptoms during Dix-Hallpike as “objective” BPPV • All other subjective symptoms will be the same as typical BPPV, but intensity of vertigo may be less severe • Responds well to canalith repositioning such as Epley Maneuver (Hubner et al 2013) • Hypotheses • resolving BPPV with only a small amount of ootoliths in the canal (Alverenga et al. 2011) • Chronic canalothiasis within the short arm of posterior canal (Büki et al. 2011) 86
  • 87. WHEN SYMPTOMS/FINDINGS CONCERNING FOR VBI • Refer to physician to consider arterial imaging • CTA highest sensitivity (100%) vs. MRA (77%). (Systemic Review, Gottesman 2012) • Angiogram may be needed for intracranial VA segment • In the rare case of suspected VA rotational occlusion (bow hunters syndrome), angiogram in rotation most sensitive (Goo et al 2013) 87
  • 88. BPPV VS. VBI • BPPV will not have additional neuro symptoms, central ocuolmotor findings or other abnormal neurological findings • Dix-Hallpike Testing will not fit typical BPPV pattern in VBI • VBI symptoms during Dix-Hallpike will not resolve in <1 min, will not fatigue with repeated testing and will have central nystagmus patterns (downbeating, pure vertical or direction changing) 88
  • 89. MUSCULOSKELTAL CERVICAL DIZZINESS VS VBI • Presence of VBI symptoms + history of stroke risk factors or recent head/neck trauma (even minor!) = imaging is needed!! • If low suspicion of VBI + findings of c-spine dysfunction, a trial of gentle manual therapy to c-spine will very likely reduce symptoms of dizziness/nystagmus with immediate re-test of cervical rotation 89
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  • 91. HINTS TESTING IN PT WITH VESTIBULAR NEURITIS 91

Editor's Notes

  1. Dizziness produced with seated neck rotation NOT indicative of BPPV; likely cervicogenic. Need to consider VBI, if c/o other VBI symptoms + stroke risk factors or recent neck trauma (even minor!)
  2. Term “Positional” can be misleading because it’s present when moving from one position to another. Not by static positions. In older adults, ~50% of dizziness due to BPPV
  3. Organs for detecting head movements = utricle, saccule and semi-circular canals Otoconia of calcuim carbonate crystals in utrice and saccule that deflect in response to acceleration movement, causing firing of the hair cells Ampula in the base of semi-ciruular canals will deflect in response to angluar movement of fluid in the canal
  4. The otoconia, which is heavier than the endolymph, fall toward the cupula and bring on endolymphatic flow in an ampullopetal direction, causing stimulation of the HC Otoconia present in the canal changes the speed of movement in the canal Can also develop BPPV due due Virus that causes vestibular neuritis/labyrithitis and Meniere’s disease Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ 2003;169:681–93. You become dizzy because now that rate that should be happening equally on both sides is mismatched. This mismatch of signals from the nerves on either side results in dizziness. Because the nerve on one side is telling you where your head is at, and how fast it’s moving, and the nerve on the other side is giving you different information. The result is dizziness! Dizziness stops when the otoconia stop moving.
  5. Canalithiasis: MOST COMMON Otoconia in the semi-circular canal. Otoconia moving in the canal produces symptoms Symptoms resolve once otoconia stop moving
  6. Anteior Canal: Will have Downbeating/torsional nystagmus in Dix-Hallpike, however Downbeating nystagmus without torsion is a CENTRAL finding Bilateral rare: But can be more common after trauma (Katsarkas 1999) Cupulolisthiasis: Will produce non fatiguing dizziness and nystagmus in the test position. Need to consider cervicogenic cause (vascular or musculoskeleta
  7. When interviewing the pt, they will appear well. May have learned to avoid the provoking movements. If  
  8. Start at 0:20 Dr. Teixido – Otolaryngologist from Deleware
  9. Cannot make diagnosis based on subjective history alone
  10. Maintain position at least 30-45 sec while observing for vertigo and nystagmus Slowly return to sitting (sometimes will have reversal of nystagmus). Dizziness with return to sit not a + finding Repeat on the opposite side
  11. Named for the fast phase Wil l someimes l have a reversal of nystagmus during return to sitting Upbeating = Posteior Canal (85-95% of all cases) Downbeating = Anterior Canal (RARE. Also can be a CENTRAL finding) R torsion = R side involved L torsion = L side involved Vertigo and nystagmus < 1 min = CANALISTHIASIS Vertigo and nystagmus > 1 min = CUPULOLISTHIASIS RARE! Consider other non-BPPV causes as well Nystagmus will have vertical AND torsional component toward the effected side. Named for the fast phase.
  12. Special considerations are warranted in the geriatric population, because geriatric patients with BPPV usually report dizziness or imbalance and do not always describe a rotatory crisis. Batuecas-Caletrio and colleagues have argued that the Dix-Hallpike and supine roll tests should be performed in older patients with dizziness, despite the fact that they do not complain of spinning sensation with positional changes
  13. Canalith = Otolith
  14. Each position is maintained for about 30 seconds to allow the particles to move by gravity into a different part of the canal. 
  15. Higher recurrence in elderly (Batuecas et al 2013) and with head trauma (Liu 2012)
  16. Gaze holding aka eccentric gaze If pt has clear subjective symptoms of BPPV may be uneccessary to do oculomotor exam unless findings on Dix-Hallpike do not confirm.
  17. Most will eventually have complete hearing loss in effected ear No other neuro symptoms, usually normal oculomotor testing
  18. Easy to differentiate from BPPV BPPV: vertigo < 1 min, brought on by change in head position relative to gravity BPPV = No presence of spontaneous nystagmus, gaze holding nystagmus, or other CENTRAL oculomotor findings AVS: constant vertigo, worsened by change of head position AVS: +spontaneous and/or gaze holding nystagmus
  19. . High false neg because of Physiolgoical symptoms prior to anatomical changes Up to 35% of strokes can be missed when presenting with vertigo and dizziness
  20. Stroke risk factors: smoking, hypertension, diabetes, hyperlipidemia, atrial fibrillation, eclampsia, hypercoagulable state, recent cervical trauma, prior stroke, or myocardial infarction Repeat delayed MRI was obtained in patients with initially normal imaging if clinical signs suggested a central lesion or new neurologic signs appeared during the inpatient admission Sensitivity: 96.5%, Specificity: 84.4% (Newman) Central eye movement findings predict stroke with high accuracy (Tarnutzer et al 2011)
  21. https://www.youtube.com/watch?v=Wh2ojfgbC3I Can see it best at the end of video
  22. Only 20% of patients with central lesions had direction changing. But very specific when you see it.
  23. +spontaneous nystagmus to the L L beating nystagmus looking L R beating nystagmus looking R http://www.kaltura.com/index.php/extwidget/preview/partner_id/797802/uiconf_id/27472092/entry_id/0_jw26j6hk/embed/auto?
  24. + vertical eye movement https://www.youtube.com/watch?v=zgqCXef-qP
  25. Nystagmus in gaze holding DIRECTION CHANGING = highly specific, but only present 20% in HINTS study
  26. Head impulses assess the integrity of primary vestibular pathways from the labyrinth to the lateral pons.40 Tests for gaze-evoked nystagmus assess gaze-holding circuits in the brainstem and cerebellum.41 Tests for vertical ocular alignment primarily assess central otolithic pathways in the brainstem. NOT that hard to learn. PT’s especially good. No data on interrater reliability of HINTS between specialists and EPs, but novice and experienced specialists interpret head impulse test result
  27. Oostendorp [23] reported a latency period of approximately 55 seconds after assuming a cervical extension-rotation position for patients with suspected VBI
  28. f there are other potential explanations, they need to be ruled out!! Vertigo uncommon, but ~50% whiplash pts report dizziness and imbalance (Oostervield et al 1991, Skovoron et al 1998 Oosterveld WJ, Kortschot HW, Kingma GG, et al. Electronystagmographic findings following cervical whiplash injuries. Acta Otolaryngol 1991; 111: 201–205. Skovron ML. Epidemiology of Whiplash. In: Szpalski M, Gunzburg R, editors. Whiplash injuries: current concepts in preventions, diagnosis, and treatment of the cervical whiplash syndrome. Philadelphia: Lippincott-Raven; 1998. pp. 61–67.
  29. Dominant VA compressed at C1-2 level during contralateral neck rotation Compromises blood flow in the vertebrobasilar artery territory Rare, most reports are case series.
  30. Oostendorp R. Functionele Vertebrobasilaire Insufficientie [Functional Vertebrobasilar Insufficiency]. Dissertation. Nijmegen, The Netherlands: Katholieke Universiteit Nijmegen; 1988
  31. .
  32. Vertebral Artery or Internal Carotid involved Firstly, the flow through the blood vessel may be disrupted due to the accumulation of blood under the vessel wall, leading to ischemia. OR irregularities in the vessel wall and turbulence increase risk of thrombosis and embolism = MORE COMMON
  33. catching volleyball overhead, playing Wii, rugby, racing go-cart, difficult dental extraction, overhead house painting high impact gym exercises, running on treadmill while using arm support, sustained flexion in child birth, lifting a heavy object on 1 shoulder Less common symptoms: balance disturbance, generalized limb weakness, non-dermatomal paresthesia, ptosis Cardiovascular risk factors (HTN and HL), with the exception of migraine, not strongly associated with cervical artery dissection
  34. lung surgery, appendectomy, cholecystectomy, head trauma Mentioned turning to the L as aggrivating to many providers
  35. HINT neg for central, but skew deviation not tested Head Impulse/head thrust (neg) Nystagmus: +L gaze unilat (peripheral) Test of Skew – N/T Dix Hallpike neg G
  36. No HINTS exam in ED
  37. Doesn’t clearly fit HINTs criteria for either peripheral or central. Signs concerning for central due to pt symptoms and findings with sustained neck rotation Spontaneous nystagmus: negative Gaze-holding nystagmus: +for direction changing nystagmus (R>L) Eye movement ROM: WNL Vergence: NT Smooth pursuit eye movements: negative Saccadic eye movement: + on the R and L VOR Cancellation: WNL Head Thrusts Horizontal: consistently + to the R, IM + to the L Static and Dynamic Visual Acuity: WNL, 7 lines in each condition Easing: meclizine helps control the spinning sensation
  38. “Repeat MRI brain w/wo contrast with thin cuts through brainstem as well as base of skull.”
  39. Oculomotor still with + overshoot with saccade and direction changing nystagmus with lateral gaze PT: initiated habituation exercises for motion sensitivity, VOR retraining, balance training
  40. BPPV Clinical Practice Guidelines: Bhattacharyya, Neil et al. Clinical practice guideline: Benign paroxysmal positional vertigo Otolaryngology–Head and Neck Surgery (2008) 139, S47-S8
  41. Unable to isolate 1 horizontal canal during testing
  42. Others suggest that this condition may be related to chronic canalolithiasis within the short arm of a posterior canal [145] J Am Acad Audiol. 2013 Jul-Aug;24(7):600-6. doi: 10.3766/jaaa.24.7.8.  Treatment of objective and subjective benign paroxysmal positional vertigo. Huebner AC1, Lytle SR, Doettl SM, Plyler PN, Thelin JT. G. A. Alvarenga, M. A. Barbosa, and C. C. Porto, “Benign Paroxysmal Positional Vertigo without nystagmus: diagnosis and treatment,” Brazilian Journal of Otorhinolaryngology, vol. 77, no. 6, pp. 799–804, 2011 B. Büki, L. Simon, S. Garab, Y. W. Lundberg, H. Jünger, and D. Straumann, “Sitting-up vertigo and trunk retropulsion in patients with benign positional vertigo but without positional nystagmus,” Journal of Neurology, Neurosurgery and Psychiatry, vol. 82, no. 1, pp. 98–104, 2011
  43. CT more risky due to radiation and toxicity of contrast dye – may not be suitable
  44. VOR: rotation of the head signals inhibiatory signal to the extraocular muscles on one
  45. https://www.youtube.com/watch?v=BNP5UiRlmiU https://youtu.be/BNP5UiRlmiU All 3 tests consistent with peripheral findings 1. Head Impulse: + catch up saccade 2. + Gaze holding nystagmus to R = horizontal unidirectional 3. Neg test of skew