Vertigo

Introduction

• Vertigo = Sensation of movement when no movement exists
  • Subjective – They are moving in relation to surroundings
  • Objective – Their surroundings are moving around them
• Disequilibrium = Feeling of imbalance or ‘floating’ while walking
• Acute vestibular syndrome
  • Symptom complex of vertigo, nausea and vomiting, intolerance to head motion, spontaneous nystagmus, unsteady gait and postural instabiilty caused by injury to peripheral or central vestibular structures
  • Must persist for at least 24 hours (thus excluding transient vertigo e.g. BPPV)
  • Clinical features that differentiate central causes are focal neurological deficits or gaze palsy
  • Most common peripheral cause is vestibular neuronitis
  • Most common central cause is ischaemic stroke of posterior fossa (brainstem or cerebellar)
  • 25% of patients presenting with AVS have had a stroke

Nystagmus

• Rhythmic movement of the eyes with fast and slow components
• Direction = Fast component
• Slow component is due to vestibulo-ocular reflex with eye movement away from pathological canal
• Fast component is the saccadic correction by the cortex
• Vestibular disorders produce nystagmus provoked when affected side is in dependent position and is typically vertical + rotational OR horizontal
• Vertical nystagmus by itself = brainstem

Differential

• Vestibular
  • BPPV, traumatic, labyrinthitis, vestibular neuronitis, Ramsay Hunt syndrome
• Systemic conditions affecting the vestibular system
  • Meniere’s, neoplastic, vascular, otosclerosis, Paget’s disease, aminoglycosides
• Neurological
  • Vertebrobasilar insufficiency, vertebral artery dissection, Lateral Wallenberg’s syndrome, AICA syndrome, cerebellopontine angle tumors, cerebellar haemorrhage/infarct, basal ganglion disease, MS, neurosyphilis, neuroTB, epilepsy, migraine headaches, cerebrovascular disease
• General
  • Anaemia, polycythaemia, hyperviscosity syndrome, toxic alcohol, chronic renal failure, thyroid disease, hypoglycaemia

Peripheral vs. Central

Differential diagnosis based on duration

Dizziness categorisation

* Central paroxysmal positional vertigo may mimic BPPV but is caused by mass, haemorrhage or posterior fossa demyelination. It is differentiated from BPPV by other features (e.g. headache, diplopia, CN abnormalities, ataxia), high-risk nystagmus or failure to improve with canalith repositioning maneuvers.

Dizziness algorithm

*Dizziness red flags include pathological high-risk nystagmus, dysmetria and truncal ataxia when seated.

History

• Avoid leading questions but obtain unprompted description
• Acute vestibular syndrome (by definition >24 hours) rules out BPPV, Meniere’s and TIA
• Ascertain if features consistent with peripheral or central
• Recent head or neck trauma = vertebral artery dissection until proven otherwise ‘NOT JUST CONCUSSION’
• Evaluate risk groups for central vertigo specifically
  • Older patients, HTN, cardiovascular disease, other risk factors for stroke e.g. AF or those taking warfarin
• Acute vestibular syndrome + >1 risk factor for stroke are at particular risk of central vertigo
• Patients >50 with AVS and no neurological signs are still more likely to be suffering from vestibular neuronitis than stroke
• Peripheral vertigo tends to cause severe symptoms but is seldom life-threatening; the reverse is true for central

Examination

• Complete ENT, neuro and vestibular examinations
• Focal neuro deficits found in 80% of patients with stroke as cause for AVS
• Presence of gait unsteadiness and severe truncal ataxia (inability to sit unaided with arms crossed) suggests stroke
• Positive Romberg test is rare in peripheral vertigo

HiNTS testing:
Original article (Dr Newman-Toker)

• 101 ‘high-risk’patients with acute vestibular syndrome
  • Definition: Vertigo, nausea, vomiting and unsteady gait with or without nystagmus with 1 or more stroke risk factors
  • Exclusion: previous vertigo, obvious peripheral source, obvious central or oculomotor signs
  • Both first presenters to ED and those already diagnosed as posterior stroke on imaging studies
  • Exam conducted by 2 very experienced practitioners who performed full histories and examinations before HINTS examination
  • Thus, it is a study of experienced practitioners being able to discern central from peripheral acute vestibular syndrome from hx and exam
• 76% of patients had central cause (very high vs. ED population)

How useful is HiNTS in the ED?

• No one knows
• Has not been validated in an ED population with vertiginous symptoms
• Original study was highly selected and had gait/truncal ataxia for inclusion
• Not clear how helpful in undifferentiated, far more subtle presentation
• May be useful if performed in conjunction with full hx and examination to assist in ruling out central aetiology for vertigo
• However, validation study in similar/same cohort showed sensitivity of 96.8% (not good enough for ruling out CVA)

How do you do HiNTS testing?

• Head impulse testing
  • Lateral rotation 20 degrees each way then rapidly back to midline looking for tracking abnormalities
  • Deviation off focus and/or saccadic corrections indicate peripheral lesion
• Nystagmus
  • Direction changing or vertical nystagmus = central
• Test of skew
  • Vertical test of skew = Central

Misdiagnosis in ED

• One study showed 50% of patients misdiagnosed as peripheral vertigo were under 50 years old
• Almost all had incomplete or poorly documented neuro exam
• Almost all had a CT interpreted as normal initially
• Overall mortality was 40% with 50% of survivors having disability

HINTS PLUS

• Adds Hearing loss as an indicator of central aetiology (stroke)

Guideline approach

• Not true vertigo
  • Elderly
    • Consider disequilbrium of ageing
    • Obtain orthostatic BP, FBC, ECG and consider medical admission
  • Young
    • Obtain same tests
    • Consider psychiatric dizziness
• True vertigo
  • Suspicious for central
    • Brief symptoms = TIA – Check for carotid bruits, echo, consider antiplatelet/anticoagulant therapy
    • Constant = Stroke/MS – CT/CTA, admission for MRI
  • Suspicious for peripheral
    • Precipitated by head movements – BPPV
    • No hearing loss – Vestibular neuronitis
    • Hearing loss and no tinnitus – Acoustic neuroma
    • Hearing loss and tinnitus without recent infection – Meniere’s
    • Hearing loss, tinnitus and recent otitis media/URTI – Consider bacterial labyrinthitis

Treatment

• Symptomatic treatment for peripheral vertigo
  • Antiemetic and vestibular apparatus suppressants are crucial for patient comfort but should be withdrawn ASAP to allow central vestibular compensation
  • Metoclorpamide
  • Ondansetron
  • Promethazine (Phenergan) 25mg PO TDS (EPSE rarely)
  • Prochlorperazine (Stemetil) 5-10mg TDS

Nystagmus

• In acute peripheral vestibular loss, nystagmus is unidirectional
  • Direction of nystagmus is unaffected by changes in gaze direction
  • Slow phase in direction of the defunct labyrinth (fast phase beating to contralateral side)
  • Can still be seen in central lesion affecting brainstem origin of vestibular neurons
• Suppression of nystagmus in peripheral disease
  • Nystagmus is suppressed when visual fixation is allowed
  • Can observe increased intensity behind closed eyelids

Positional nystagmus and smooth pursuit

• Positional nystagmus
  • Latency, habituation and fatiguability seen in peripheral lesions
  • No latency, no habituation and no fatiguability in central lesions
• Smooth pursuit
  • Intact in peripheral lesions
  • Broken in ipsilesional direction with central causes

BPPV

• Commonest cause of acute vertigo but often missed if history not classical or Hallpike-Dix manoeuvre not performed
• Lifetime incidence of 2.4% and 1-year incidence of 0.6%
• Women and patients >50yo most at risk
• Mean duration of an episode is 2 weeks and 86% of patients seek medical attention
• Caused by inappropriate activation of semicircular canal (typically posterior and unilateral) due to otoconia
• Posterior (85%) vs. horizontal (10-15%) vs. anterior (1%)
• Onset is sudden and precipitated by rolling over in bed, leaning forwards, looking up at sky or ceiling or turning the head
• Symptoms fatigue and are therefore usually worse in the morning
• No associated hearing loss, tinnitus or physical findings on ENT or neuro examination

• Supportive findings
  • Latency of <30 seconds between head positioning and onset of nystagmus
  • Intensity of nystagmus increases to peak then slowly resolves
  • Duration of vertigo and nystagmus is 5-40s
  • If nystagmus is produced in one direction by head down, then reverses direction when head is returned to upright position
  • Repeated head positioning causes the vertigo and nystagmus to fatigue
  • Abnormal head impulse testing
  • HINTS testing not indicative of central cause
  • No spontaneous nystagmus
  • Romberg test negative and normal gait
  • Positive canal BPPV -> Dix-Hallpike positive -> Modified Epley
  • Horizontal canal BPPV -> Pagnini-McClure positive (supine position with head turned to each side) -> Gufoni manoeuvre
  • Anterior canal BPPV (very rare) -> Downbeating nystagmus with affected ear upwards (need to consider central cause)
• Diagnostic manoeuvres
  • Dix-Hallpike
    • Tests posterior canal on downward ear
    • Sitting up, turn head to right 45 degrees
    • Lie down with head hanging 20 degrees off end
    • Remains for 30 seconds then sit up
    • Observe for 30 seconds then turn head to left and lie down
    • Positive test if any of these movements produce vertigo with or without nystagmus
    • Torsional nystagmus for the ear that is down
    • Pure horizontal or vertical nystagmus is concerning
    • Downbeating vertical nystagmus with affected ear upwards suggestive of anterior canal BPPV but is also concerning for central aetiology
    • Peripheral
      • 2-40 seconds latency
      • Fatiguable
      • Severe
      • Usually <1 minute of nystagmus
      • Habituation observed if done repeatedly
    • Central
      • No latency
      • Not fatiguable
      • Mild
      • Usually >1 minute of nystagmus
      • No habituation observed
  • Pagnini-McClure (Supine roll test)
    • Tests the horizontal/lateral canal
    • Supine with head in 30 degrees flexion
    • Rotate 90 degrees to one side
    • Look for nystagmus with latency and fatigue
    • Return to supine position
    • Then turn head to opposite side
    • Return to supine position
    • Positive test will induce vertigo with horizontal nystagmus
      • Geotropic horizontal towards earth on affected side with affected side being the one with the worst nystagmus
      • Apogeotropic (less common) horizontal towards upper ear on both sides with side affected being the one opposite the most intense nystagmus

Therapeutic maneouvres

• Modified Epley manoeuvre
  • With head in finishing position of Hallpike, wait for nausea to pass
  • Turn head 90 degrees away from affected ear (i.e. as if testing other one)
  • Wait 30-60 seconds
  • Ask patient to roll away from affected side holding head at same angle (end up on side, looking almost down with affected ear up)
  • Wait 30-60 seconds
  • Swing legs over couch and sit up slowly
  • Turn head to midline, flexing neck a little
  • Wait 30-60 seconds
  • Minimise head movement for next 24 hours
  • Repeat every few days
  • 1/20 resistant to Epley manoeuvre
• Gufoni manoeuvre
  • For horizontal/lateral canal BPPV
  • Geotropic
    • Lie patient on side, with affected ear down for 1 minute
    • Turn patients head 45 degrees towards the ground for 2 minutes
    • Sit the patient up
  • Apogeotropic
    • Lie patient on side, with affected ear down for 1 minute
    • Turn patients head 45 degrees away from the ground for 2 minutes
    • Sit the patient up
  • Repeat up to 3 times if ongoing nystagmus on supine roll test
  • It is not uncommon for the Gufoni manoeuvre to convert geotropic to apogeotropic requiring further Gufoni attempts to treat what is evident on supine roll testing

Vestibular neuronitis

• Commonest cause of acute vestibular syndrome (AVS) and second most common cause of peripheral vertigo (to BPPV)
• Typically last days and does not recur
• Sudden onset with recent viral illness
• Positive head impulse
• Romberg negative but gait tends to be slow, caution and wide-based
• Remits spontaneously with no recurrence
• Treatment is symptomatic and there is insufficient evidence for valacyclovir or methylprednisolone

Vestibular ganglionitis (Ramsay Hunt)

• Thought to be due to VZV reactivated years after infection
• Deafness, vertigo and facial nerve palsy
• Grouped vesicles inside external auditory canal
• Treated with antivirals started within 72 hours along with symptomatic treatments

Labyrinthitis

• Infection of labyrinth causing peripheral vertigo and hearing loss
• Viral (measles or mumps) 
• Bacterial may be a sequelae of OM, meningitis, mastoiditis, cholesteatoma
• Sudden onset of vertigo with associated hearing loss and middle ear examination findings
• At risk of meningitis and need treatment with antibiotics and referral to ENT

Cerebellar stroke

• Vertigo is the most common symptom in cerebellar stroke
• If no brainstem involvement, this may be the only symptom
• Red flags include: Occipital headache, hyperacute onset or profound gait ataxia
• Intact head impulse testing
• Hearing loss can occur if vertebrobasilar ischaemia has affected the auditory nerve nuclei
• Common criteria for imaging are vertigo +
  • New onset occipital headache
  • Acute central neurological symptom or sign
  • Acute deafness
  • Intact head impulse test

Migrainous vertigo

• Diagnosis of exclusion
• Easy diagnosis if coincident migraine headaches with vertigo
• Typically migraneur with increasing headache frequency and development of vestibular episodes, but not concurrently
• May have non-headache migraine symptoms also
• May have isolated vertigo
• Inter-ictal testing should be normal
• Ergotamine and sumatriptan should be avoided in basilar migraine

Ototoxicity

• Due to bilateral nature, vertigo often is absent or minimal
• Most commonly aminoglycoside toxicity
• Often present with ataxia and oscillopsia (inability to maintain visual fixation while moving)
• Must be considered in critically ill ’dizzy’ patients
• Avoid long-term use of antivertigo or benzodiazepine medications as these inhibit compensatory mechanisms

Ototoxicity

Drug-induced central vertigo

• TCA
• Neuroleptics
• Opiates
• Alcohol
• Anticonvulsants can cause dizziness and ataxia
• Lamotrigine can cause dizziness
• Phenytoin and chemotherapeutics can cause irreversible cerebellar toxicity
• Avoid using any antivertigo or benzodiazepine medications on a long-term basis as prevents compensatory mechanisms

CN VIII lesions and cerebellopontine angle tumors

• Meningioms and acoustic neuromas (Schwannomas) produce mild vertigo
• Usually gradual onset and constant until central compensation occurs
• Hearing loss often precedes vertigo
• Cerebellopontine angle tumors usually present with deafness and ataxia + ipsilateral facial nerve palsy, loss of corneal reflex and cerebellar signs

Post-traumatic vertigo

• Direct injury to labryinthine membranes
• Onset of vertigo is immediate
• May have concomitant temporal bone fracture
• Tends to resolve over weeks
• Closed head trauma can displace otoconia leading to BPPV
• Post-concussive syndrome may have unsteady gait and vague sense of dizziness

Acute vertigo with deafness

• Meniere’s disease
• Vertebrobasilar ischaemia
• Acoustic neuroma
• Labyrinthine haemorrhage

Meniere’s disease

• Most common cause of acute vertigo with deafness
• Due to increased endolymph within cochlea and labyrinth
• Older men and women mostly
• Usually unilateral but can become bilateral over time
• EPISODIC
  • Typically sudden onset with associated nausea, vomiting, diaphoresis lasting 20 minutes to 12 hours (not AVS)
• Frequency from several times per week to several times a month
• Associated progressive tinnitus, reduced hearing and aural fullness
• Examination
  • Peripheral vestibular nystagmus
  • Head impulse testing lateralising vestibular hypofunction to affected ear
• Can suffer acute drop attacks without other acute symptoms

• Treatment
  • Acute vertigo: Prochlorperazine (Stemetil) + PO lorazepam 0.5-1mg
  • Diuretics the only possibly proven long-term management in Australa
  • CCB for refractory cases
  • Intratympanic gentamicin for refractory cases for immediate and long-term relief
  • Refer to ENT
  • Tinnitus and hearing loss tend to be refractory to therapy (as opposed to vertigo)

Perilymph fistula

• Opening in round or oval window allowing pneumatic changes in middle ear to affect the vestibular apparatus
• Trauma, infection or pressure changes can cause the tear
• Diagnosis suggested by sudden onset vertigo while flying, diving, straining, coughing or sneezing
• May have associated hearing loss
• Diagnosis confirmed by nystagmus elicited by pneumatic otoscopy
• Refer to ENT and bed rest

Vertebrobasilar ischaemia

• Brainstem stroke causing acute hearing loss and vertigo
• TIA of brainstem can present like peripheral vestibular disorders with episodic vertigo
• Typical risk factors for cerebrovascular disease
• May be accompanied by diplopia, dysphagia, dysarthria, bilateral long-tract signs and bilateral loss of vision
• May be provoked by position as turning the head or looking up can occlude the ipsilateral vertebral artery with contralateral vertebral artery stenosis usually required for TIA of brainstem to occur
• Usually hearing loss is actually peripheral in nature i.e. occlusion of internal auditory artery which supplies membraneous labyrinth (branch of AICA)
• Almost always concomitant brainstem signs

Vertebral artery dissection

• Dizziness, headache and neck pain
• ¼ patients will not have headache
• Headache is usually sudden and severe onset with recent head or neck trauma
• Trauma may be a minor MVA, coughing or sneezing
• Usually <50yo

Multiple sclerosis

• Can present with vertigo lasting hours to weeks and usually non-recurrent
• Vertigo is mild with nystagmus
• MRI is confirmatory

Labyrinthine haemorrhage

• Acute severe hearing loss and vertigo
• Rare

Wallenberg’s syndrome

• Lateral medullary syndrome
• Classic vertigo +
  • Ipsilateral facial numbness, loss of corneal reflex, Horner’s syndrome and paralysis of soft palate, pharynx and larynx (dysphagia and dysphonia)
  • Contralateral loss of pain and temperature sensation in trunk and limbs (crossed signs)

Disequilibrium of ageing

• Ill-defined dizziness and gait unsteadiness associated with loss of hearing, balance, proprioceptive input, vision with altered postural reactions, reactional hypertonia, gait modification and fear of falling
• Symptoms often worse in reduced ambient light, unfamiliar surroundings, benzodiazepine or anticholinergic use

STANDING algorithm

• Sensitivity for central vertigo of 100% (95% CI 72.3%-100%)
• Specificity for central vertigo of 94.3% (95% CI 90/7-94.3%)
• PPV 68.8% (95% CI 49.7-68.8%)
• NPV 100% (95% CI 96.3-100%)

References

• HiNTS article
• A practical approach to acute vertigo. Seemungal and Bronstein. Practical Neurology. 2008; (8) 211-221

Last Updated on October 31, 2023 by Andrew Crofton