vertigo
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Introduction
The sensation of abnormal movement, often described as a spinning of the surroundings or the body.
Classification
Pathology
imbalance of tonic vestibular signals
History
- duration of symptoms, episodic nature, severity, positional effects, hearing loss, weakness, ataxia, paresthesias, diplopia, tinnitus, nausea/vomiting, head trauma, recent upper respiratory tract infection, ear infections
Physical examination
- Hallpike maneuver
- Valsalva maneuver decreases cerebral blood flow reproducing symptoms of ischemia
- rapid rotation & abrupt cessation in a swivel chair
- hyperventilation for 1 minute
- HINTS
Clinical manifestations
(peripheral vs. central vertigo)
- peripheral vertigo
- nystagmus
- unidirectional; fast phase opposite lesion (except Meniere's disease where direction is variable)
- purely horizontal nystagmus without torsional component is uncommon
- vertical or purely torsional nystagmus is NEVER present
- nystagmus is generally fatigable
- visual fixation inhibits nystagmus & vertigo
- severity of vertigo is generally marked
- direction of spin is toward fast phase
- direction of fall is toward slow phase
- duration of symptoms is finite (minutes, days, weeks), but recurrent
- tinnitus &/or hearing loss is often present
- positive head thrust test[14]
- associated CNS abnormalities are NOT present
- nystagmus
- central vertigo
- nystagmus
- may be unidirectional or bidirectional
- purely horizontal nystagmus without torsional component is common
- vertical or purely torsional nystagmus may be present
- nystagmus is not fatigable
- immediate nystagmus with Dix-Hallpike manuever[3]
- nystagmus may be spontaneous[3]
- nystagmus may change in direction[14]
- visual fixation does NOT inhibit nystagmus or vertigo
- severity of vertigo is often mild
- direction of spin is variable
- direction of fall is variable
- duration of symptoms may be chronic
- tinnitus &/or hearing loss is generally absent
- vertical skew in HINTS test of skew deviation
- negative head thrust test[14]
- associated CNS abnormalities are generally present
- diplopia, dysarthria, focal neurologic sign, ataxia, headache
- 20% of patients with vertebrobasilar stroke present with isolated vertigo
- nystagmus
Laboratory
- exclusion testing
Diagnostic procedures
- audiometry
- auditory brain stem response (ABR)
- distinguishes cochlear from retrocochlear pathology (acoustic neuroma)
- persistent vertigo or diagnostic dilemma
- electronystagmography - hypoactive cold caloric test
- rotational chair
- dynamic posturography
- a three-component bedside oculomotor examination (HINTS) appears to rule stroke in or out with more accuracy than urgent diffusion-weighted MRI[9]
Radiology
- magnetic resonance imaging (MRI) of brainstem & internal auditory canals[14]
- vertigo associated with
- hearing loss
- tinnitus
- ear fullness
- persistent rather than paroxysmal or transient vertigo
- evidence of central vertigo
- vertigo associated with
- computed tomography (CT) with contrast (less useful than MRI)
Complications
- absolute risk of vascular event after presenting with an episode of vertigo is low (stroke within 1 month < 1 in 500) [4.8]
- RR* for stroke is with 30 days is 9, suggesting that cases of central vertigo can be misdiagnosed as peripheral vertigo[8]
* RR = relative risk for emergency department visits related to vertigo relative to those for renal colic
Management
- depends upon specific type
- central vertigo warrants immedicate neurosurgery consultation
- single-dose antihistamines provide greater vertigo relief at 2 hours than single-dose benzodiazepines[13]
- evidence does not support an association of benzodiazepine use with improvement in any outcomes for acute vertigo[13]
- daily antihistamine use may not benefit patients with acute vertigo[13]
More general terms
More specific terms
Additional terms
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1013-15
- ↑ Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 104-107
- ↑ 3.0 3.1 3.2 Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2012, 2015, 2018, 2021.
Post RE, Dickerson LM. Dizziness: a diagnostic approach. Am Fam Physician. 2010 Aug 15;82(4):361-8, 369. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20704166 - ↑ Kim AS et al. Risk of vascular events in emergency department patients discharged home with diagnosis of dizziness or vertigo. Ann Emerg Med 2011 Jan; 57:34 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20855127
- ↑ Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
- ↑ Badaracco C, Labini FS, Meli A, De Angelis E, Tufarelli D. Vestibular rehabilitation outcomes in chronic vertiginous patients through computerized dynamic visual acuity and Gaze stabilization test. Otol Neurotol. 2007 Sep;28(6):809-13. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17577127
- ↑ Uneri A, Polat S. Vertigo, dizziness and imbalance in the elderly. J Laryngol Otol. 2008 May;122(5):466-9. Epub 2007 Sep 13. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17850686
- ↑ 8.0 8.1 Atzema CL et al. Outcomes among patients discharged from the emergency department with a diagnosis of peripheral vertigo. Ann Neurol 2016 Jan; 79:32 PMID: https://www.ncbi.nlm.nih.gov/pubmed/26385410
- ↑ 9.0 9.1 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 PMID: https://www.ncbi.nlm.nih.gov/pubmed/21576300 Free PMC Article
- ↑ Labuguen RH. Initial evaluation of vertigo. Am Fam Physician. 2006 Jan 15;73(2):244-51. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16445269 Free Article
- ↑ Della-Morte D, Rundek T. Dizziness and vertigo. Front Neurol Neurosci. 2012;30:22-5. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22377855
- ↑ Wikipedia: Vertigp https://en.wikipedia.org/wiki/Vertigo
- ↑ 13.0 13.1 13.2 13.3 George J Benzodiazepines or Antihistamines for Acute Vertigo? Evidence does not support benzodiazepines for any outcomes, meta-analysis shows. MedPage Today July 18, 2022 https://www.medpagetoday.com/neurology/generalneurology/99779
Hunter BR, Wang AZ, Bucca AW et al Efficacy of Benzodiazepines or Antihistamines for Patients With Acute Vertigo. A Systematic Review and Meta-analysis. JAMA Neurol. Published online July 18, 2022. PMID: https://www.ncbi.nlm.nih.gov/pubmed/35849408 https://jamanetwork.com/journals/jamaneurology/article-abstract/2793943 - ↑ 14.0 14.1 14.2 14.3 14.4 NEJM Knowledge+ Otolaryngology