Vertigo
•Download as PPTX, PDF•
5 likes•1,969 views
This document discusses the assessment and management of patients presenting with vertigo. It outlines various central and peripheral causes of vertigo including vestibular migraine, brainstem ischemia, and BPPV. It also presents a case study of a 32 year old woman presenting with acute onset vertigo following viral symptoms who is assessed as likely having vestibular neuritis. The document recommends using the TiTrATE approach to classify vertigo presentations as episodic or constant, triggered or spontaneous to guide further testing and management. Physical exam findings of nystagmus patterns are also discussed to help differentiate central from peripheral causes of vertigo.
More Related Content
What's hot
What's hot (20)
Similar to Vertigo
Similar to Vertigo (20)
More from SCGH ED CME
More from SCGH ED CME (20)
Recently uploaded
Recently uploaded (20)
Vertigo
- 1. Vertigo Emma Stuckey 3rd August 2017
- 7. Assessing Vertiginous patient CENTRAL Vestibular migraine Brainstem ischaemia Cerebellar stroke Chiari malformation MS Vetebrobasilar TIA BPPV Vestibular neuritis Labyrinthine concussion Menieres Otitis media Acoustic neuroma PERIPHERAL
- 10. Why do we assess vertiginous patient? CENTRAL Vestibular migraine Brainstem ischaemia Cerebellar stroke Chiari malformation MS Vertebrobasilar TIA BPPV Vestibular neuritis Labyrinthine concussion Menieres Otitis media Acoustic neuroma PERIPHERAL
- 11. Vertebrobasilar TIA Non-focal symptoms are more frequent in patients with vertebral artery than carotid artery stenosis Compter et al Cerebrovasc Dis. 2013 Transient neurological attack before vertebrobasilar stroke Hoshino et al J Neurol Sci 2013 Transient isolated brainstem symptoms preceding posterior circulation stroke: a population-based study Paul et al Lancet Neurol 2013
- 14. Maggie C •32 yr old lady, hx vestibular neuritis •Acute onset vertigo assoc with N&V since waking •Recent viral symptoms •Difficult examination due to severe symptoms •? horizontal torsional nystagmus •Unsteady on feet
- 15. •Good story for vestibular neuritis •Young, low risk factors •Obs ward •Therapeutic Mx: IVF Ondansetron Stemetil Benzodiazepines •CCT r/v •For overnight stay
- 16. How do we assess vertiginous patient? TITRATE
- 18. SYNDROME TARGETED EXAM BENIGN DISORDER DANGEROUS DISORDER ‘SAFE-TO-GO’ FEATURES TRIGGERED EPISODIC VERTIGO L/S BP DHP etc BPPV POSTERIOR FOSSA MASS - NO pain / auditory / neurological symptoms - Asymp head stationary - Reproducible Sx - Canal specific nystagmus - Therapeutic response to maneouvres SPONTANEOUS EPISODIC VERTIGO CN EAR HX VESTIBULAR MIGRAINE MENIERES TIA SAH - NO diplopia / dangerous D’s / LOC / CN signs - ABCD2 ≤3 - Clear precipitants - NO sudden, severe or sustained pain SPONTANEOUS ACUTE VERTIGO HINTS CEREBELLAR AUDITORY VESTIBULAR NEURITIS STROKE - NO excessive vomiting or gait disorder - Max 1 prodromal episode - Walks unassisted - Reassuring HINTS + no deafness
- 20. HINTS
- 21. NYSTAGMUS Peripheral • Unidirectional • Worse on gaze towards fast beat • Fatigueable • Reversal on visual fixation • Positional Central • Purely torsional • Purely vertical • Does NOT suppress with visual fixation • Changes direction with gaze
- 22. Back to Maggie C
- 27. Age 30-40 years M=F F>M: haemorrhage
- 28. Maggie C’s pathway •Neurology admit •Supportive treatment for nausea and vertigo •Betahistine, cyclizine, ondansetron, haloperidol •Neurosurg: repeat MRI and F/U in 3/12 •Transferred to OPH Young Adult Rehab •Transfers 1x assist. Ambulation 1x assist •DC OPH 6 weeks later
- 30. References • David E. Newman-Toker and Jonathan A. Edlow. TiTrATE: A Novel Approach to Diagnosing Acute Dizziness and Vertigo. Neurol Clin. 2015 Aug; 33(3): 577–599. • Compter A, Kappelle LJ, Algra A, et al. Nonfocal symptoms are more frequent in patients with vertebral artery than carotid artery stenosis. Cerebrovasc Dis. 2013;35(4):378–384. • Hoshino T, Nagao T, Mizuno S, et al. Transient neurological attack before vertebrobasilar stroke. J Neurol Sci. 2013;325(1–2):39–42. • Paul NL, Simoni M, Rothwell PM, et al. Transient isolated brainstem symptoms preceding posterior circulation stroke: a population-based study. Lancet Neurol. 2013;12(1):65–71. • Peter Johns. The HINTS exam. Youtube video accessible on: https://www.youtube.com/watch?v=1q-VTKPweuk (last accessed July 2017) • J. H. Pula, D. E. Newman-Toker, J. C. Kattah. Multiple sclerosis as a cause of the acute vestibular syndrome. J Neurol. June 2013; 260(6):1649–1654
Editor's Notes
- Vestibular symptoms – approx 5% ED visits, 1 in 20 patients, that’s 2 patients a week. In approx 20% - underlying sinister cause VERTIGO: sensation of self-motion (of head/body) when no self-motion is occurring or the sensation of distorted self-motion during an otherwise normal head movement
- PERIPHERAL CENTRAL Ischaemia & stroke Vestibular migraine: dx if >/= 5 attacks with migraine sx in at least half and prev hx migraine like headaches. And Low ABCD2 score. Chiari malformation: congenital / aquired. F>M. Structural defects cerebullum, herniation into foramen magnum. MS : demyelinating lesions in the cerebellum, medulla or intra-pontine 8th nerve fascicle. Study Newman Toker 2013: 130 patients with AVS, 4% (7) demyelinating lesions. 5 had other occulomotor signs, 2 didn’t. Vetebrobasilar TIAS: proven that isolated episodes dizzines / vertigo = TIAs, often preceed post circ stroke. 3 papers 2013,
- Menieres: episodic vertigo associated with tinnitus, aural fullness, SNHL. Usually starts aged 20-40yrs. Disruption endolymph. BPPV: episodic vertigo triggered by changes in position. Episodes last seconds-minutes. Calcium crystals within endolymph in canals. F>M. middle aged – elderly. Vestibular Neuritis: post viral / viral inflammation of vestibular portion 8th CN. Acute onset, CONSTANT symptoms, severe, gait instability. Usually lasts 1-2 days then gradual recovery.
- Acoustic Neuroma: neuroma aka vestibular schwannoma is a benign primary intracranial tumor of the myelin-forming cells of the vestibular portion of 8th cranial nerve. Hearing loss, tinnitus + vestibular symptoms (Images from: http://www.dizziness-and-balance.com/disorders/tumors/acoustic_neuroma/tests.html)
- PERIPHERAL CENTRAL Ischaemia: risk factors. If trauma consider DISSECTION. Stroke: aneurysm, AVM Vestibular migraine: dx if >/= 5 attacks + migraine sx in at least half and prev hx migraine like headaches. And Low ABCD2 score.
- Compter A, Kappelle LJ, Algra A, et al. Nonfocal symptoms are more frequent in patients with vertebral artery than carotid artery stenosis. Cerebrovasc Dis. 2013;35(4):378–384. Hoshino T, Nagao T, Mizuno S, et al. Transient neurological attack before vertebrobasilar stroke. J Neurol Sci. 2013;325(1–2):39–42. Paul NL, Simoni M, Rothwell PM, et al. Transient isolated brainstem symptoms preceding posterior circulation stroke: a population-based study. Lancet Neurol. 2013;12(1):65–71. Vetebrobasilar TIAS: proven that isolated episodes dizzines / vertigo = TIAs, often preceed post circ stroke. 3 papers 2013,
- Two MS plaques in cerebellar white matter. NOT a common presentation for MS BUT within vestibular symptoms a significant number do have MS… see study below MS : demyelinating lesions in the cerebellum, medulla or intra-pontine 8th nerve fascicle. Study Newman Toker 2013: 130 patients with AVS, 4% (7) demyelinating lesions. 5 had other occulomotor signs, 2 didn’t. (image: Dizziness and Multiple Sclerosis (MS) Timothy C. Hain, accessed 25/7/2017)
- Chiari malformation: congenital / aquired. F>M. Structural defects cerebullum, herniation into foramen magnum. Images from: https://en.wikipedia.org/wiki/Chiari_malformation#/media/File:MRI_of_human_brain_with_type-1_Arnold-Chiari_malformation_and_herniated_cerebellum.jpg
- 2 months post partum, 2nd baby, Similar to previous episode 2 yr ago: lasted approx 2 weeks Dx Vestibular neuritis, saw private neurologist
- Decided pretty convincing vestibular neuritis, tx mx: stemetil, benzos, IVF, ondansetron. CCT to r/v. OBS ward, stay o/n rer/v in am. Stemetil – dopamine receptor antagonist Benzos – enhance GABA
- TITRATE study Triggers vs exacerbating factors. Important to differentiate Episodic VERTIGO, note nausea may continue between episodes
- L/S BP: check it is not hypoperfusion secondary to postural BP drop causing symptoms DHP – will often EXACERBATE vestibular neuritis / stroke, but don’t confuse that with triggering an attack.
- Peter Johns
- Next morning, unfortunately her symptoms had got worse. Now unable to mobilise without frame, despite tx overnight onging vertigo N&V O/E nystagmus at rest, bi-directional, torsional, past pointing So she went off to the CT scanning
- Torsional nystagmus
- CT brain: Acute 14 x 14 x 13 mm parenchymal haematoma centred on the left middle cerebellar peduncle This may reflect an underlying lesion such as a cavernoma.
- CTA: No arteriovenous malformation or aneurysm is identified on CTA.
- MRI: Acute left middle cerebellar peduncle haemorrhage with adjacent developmental venous anomaly suggesting an underlying cavernoma as the cause for haemorrhage. The haemorrhage has mildly increased in size since 12/06/2017.
- Sporadically or familial pattern M=F, aged 30 to 40 years Dilated, thin walled capillaries that lack elastic fibers and smooth muscle Women more commonly present with haemorrhage and neurologic deficits Management: Observation Surgical resection if progressive neurologic deficit, intractable epilepsy or recurrent hemorrhage
- Important case in reminding to expect unexpected Importance of good examination skills, despite patient Sx / personal stuff