This presentation decodes all cases of Acute Vestibular syndrome. It includes any patient presenting to Emergency department with complaints of Giddiness or Vertigo. It runs through all the possible causes of Central and Peripheral Vertigo and how to differentiate them. It also teaches HINTS test which forms the basis of differentiation between Central and Peripheral Vertigo.

1. Decoding Acute
Vestibular Syndrome in
Emergency Department
- Dr Varun Patel

2. When a patient
complaints of Dizziness
-

3. Case 1 -
 A 52yr old female comes to ER with complaints of
Sudden onset dizziness with 2 episodes of vomiting
since she woke up from sleep 2 hrs back. She says
that the dizziness is more on turning the head
towards left and on lying or getting up from lying
position. Patient is k/c/o Diabetes Type 2. Vitals are
normal. ECG is normal.
What is the probable diagnosis?
How will you approach towards this patient?

4. Case 2
 A 62yr old male patient comes to ER with history of
Dizziness since 3 hrs with associated nausea. He
says that he cannot balance himself while walking.
The dizziness is not associated with change in
position and is constant since the onset. He is k/c/o
DM, HTN and Atrial Fibrillation. Patient is on
multiple medications including Amiodarone and
Ecospirin but is not on any anti-coagulants.
What is the possible Diagnosis?
What is the approach towards this patient?

5. Case 3 -
 A 29yr old female comes to ER with persistent
dizziness since 15 days and associated hearing
loss in left ear. Patient also complaints of buzzing
sound in left ear since few days. No comorbidities.
Patient has no history of imbalance while walking
and neither does she complaint of any head trauma.
What is the possible diagnosis?
What is the approach towards this patient?

6. Pre-Syncope vs Vertigo

8. Pre-Syncope
 Start with ruling out Cardiac cause first. Check for
following-
1. History of Palpitations
2. History of increase in Heart rate
3. History of Cardiac Arrhythmia in past
4. Get a 12 lead ECG (Look for Subtle signs – Know
your Dangerous Rhythms)
5. Do a 2D-ECHO screen to look for structural causes

9. Questions to consider

10. Vertiginous Syndromes

11. Vertiginous Syndromes

12. Diagnosis?

13. Diagnosis?

14. Diagnosis?

15. Brugada Types

16. Orthostatic Hypotension

21. Ataxia
 Do a complete Cerebellar examination to rule out
Cerebellar involvement.
 Note : Some people might have a chronic
Cerebellar symptoms which may make your
examination even more difficult.
Eg : A patient with previous PCA infarct comes with
exaggerated vertigo symptoms but also says that he
had baseline chronic vertigo for years after PCA infarct.

22. Cerebellar Examination

23. Sensory vs Cerebellar Ataxia

24. Romberg’s test to distinguish between Cerebellar and
Sensory Ataxia
This test has Sensitivity of 79% and Specificity of 80% to
differentiate Sensory Ataxia from Cerebellar Ataxia

25. Sensory Ataxia

26. Anatomy of Proprioceptive pathway

27. DDs for Sensory Ataxia

28. Cerebellar Ataxia - Causes

29. Cerebellar ataxia – Time dependent causes

31. True Vertigo
 1st thing to do is differentiate between Peripheral
and Central cause of Vertigo -

32. HINTS Exam -

33. HINTS vs MRI

34. When to Perform HINTS?
 It should be performed on patients who have
persistent, ongoing Vertigo and Nystagmus lasting
for Hours to Days (Acute variant).

35. Nystagmus- HINTS

36. Head Impulse- HINTS

37. Test of Skew - HINTS

40. HINTS

41. Peripheral Vertigo

43. Peripheral vertigo – Duration
related causes

44. Benign Paroxysmal Positional
Vertigo (BPPV)

45. Canalolithiasis vs Cupulolithiasis

46. Mechanism of BPPV

47. BPPV Presentation
 Classically, it will be episodic in Nature, sudden
onset and Positional vertigo.
 Vertigo is typically triggered by changing position to
affected side.
 Typical Age group is 50yrs.

48. Diagnosis of BPPV: Dix-Hallpike Test

49. Dix-Hallpike Interpretation
 Type of Nystagmus-
1. Rotatory Nystagmus: Posterior Canal BPPV (90%)
2. Horizontal Nystagmus: Lateral Canal BPPV (7%)
3. Vertical Nystagmus: Anterior Canal BPPV (1-3%)
4. No Nystagmus – Perform Pagnini-McClure test to
look for Lateral Canal BPPV

50. Pagnini-McClure Test

51. Pagnini-McClure Test

52. BPPV Treatment:
 There are various modalities of treatments available
based on canal involved:
1. Posterior Canal BPPV (Most common type) –
a. Epley’s Maneuver (Success rate – 80%)
b. Semont’s Maneuver (Success rate – 90.4%)
Some trials suggest that there is no difference in success
rate between the 2 maneuvers. We use Epley’s over
Semont’s type because of sudden jerky movements in
Semont’s type.
Note: The recurrence rate within 1 year after both
maneuvers is approximately 10-15%

53. Epley’s Manuever

54. Semont’s Maneuver

55. BPPV Treatment:
2. Lateral Canal BPPV: (Diagnosed by Pagnini McClure
Test)
a. Barbecue roll Maneuver (Success Rate – Appx
75%)
b. Gufoni Maneuver (Success Rate – 47.1%)
We prefer Barbecue roll Maneuver as per current
guidelines to treat Lateral Canal BPPV

56. Barbecue roll Maneuver

57. In which cases will we perform a
HINTS and a Dix-Hallpike test in
same patient?

59. Other causes of Peripheral Vertigo

60. Other Causes of Peripheral Vertigo

61. Treatment of other causes of
Peripheral Vertigo
 Acute Vestibular Neuritis – Steroids
(Methylprednisolone)
 Migraine – NSAIDs, Triptans
 Menneire’s Disease – Diuretics (Acetazolamide),
Betahistine
 Acoustic Neuroma – Surgical Excision of Tumour

62. Thank you