see: [Dunn's - vertigo](x-devonthink-item://B016DF92-143C-4A1B-B828-918BAF07E97F), [Rosen Dizziness and vertigo](x-devonthink-item://BCF138F9-E70E-482B-ABF8-7A700C65D3CA) see also: [[Diplopia]], [[Dizziness]] #tables #OSCE > **True vertigo:** sensation that surroundings are spinning around the patient > can be difficult to tell if pt is describing vertigo or [[Syncope|pre-syncope]] > - **peripheral vertigo** is caused by disorders affecting the vestibular apparatus and 8th cranial nerve > - **central vertigo** caused by disorders affecting brainstem and cerebellum central - cerebellar infarction - vertebrobasilar insufficiency - [[carotid and vertebral artery dissection|vertebral artery dissection]] - MS - space occupying lesion peripheral - BPPV - meniere disease - vestibular neuronitis (hearing function preserved) - labyrinthitis (hearing loss) - post-traumatic - CN VIII lesion **tintinalli causes of vertigo table** - vestibular/otologic - BPPV - traumatic following head injury - infection: labyrinthitis, vestibular neuronitis, Ramsay Hunt syndrome - systemic conditions with vestibular/otologic effects - meniere's syndrome - neoplastic on - vascular - otosclerosis - paget's disease - aminglycosides - neurologic - vertebrobasilar inusufficiency - [[carotid and vertebral artery dissection|vertebral artery dissection]] - lateral wallengberg's syndrome - anterior inferior cerebellar artery syndrome - neoplastic: cerebellopontine angle tumours - cerebellar disorders: haemorrhage, degeneration - basal ganglion diseases - [[Multiple Sclerosis]] - infections: neurosyphilis, tuberculosis - [[Seizures|epilepsy]] - [[Headache|migraine]] - cerebrovascular disease - general - haematologic: anaemia, polycythemia - toxic: [[Alcohol-related disease|EtOH]] - chronic renal failure - metabolic: thyroid disease, hypoglycaemia | sx | peripheral | central | | ------------------------- | -------------------------- | --------------------------------------- | | onset | sudden | sudden or slow | | severity | intense spinning | can be vague | | pattern | paroxysmal or intermittent | constant | | HINTs exam | usually normal | abnormal on at least one of three tests | | head impulse test | abnormal | usually normal | | nystagmus | horizontal | vertical or direction changing | | changes with positioning? | yes | variable; generally no | | fatigue of sx, signs? | yes | no | | headache | rare | common | ![[Pasted image 20240308164126.png|tintinalli vertigo algorithm]] # HINTS exam | component | clinical significance | | -------------------------------- | -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | head impulse test | - *abnormal (with corrective saccade) c/w *peripheral vertigo* as it suggests dysfunction to the peripheral nerve<br>- **normal** (no saccade/correction on head provocation) suggests **central** cause | | Nystagmus | - *horizontal* nystagmus suggests *peripheral*<br>- **vertical** nystagmus or those that change direction suggests **central** cause | | Test of skew<br>(skew deviation) | - **abnormal skew** with quick vertical gaze corrections (ocular tilt) suggests likely **central** cause | # Dix-hallpike test - not for differentiating central from peripheral - can help confirm presence of ==posterior semicircular canal disease== (only tests this canal) - don't do in patients with severe vertigo at rest -- will exacerbate symptoms and not help in diagnosis **technique** - patient in sitting position - support head while patient rapidly spines to 30 deg below horizontal - first with head straight - then head turned 45 deg to left - then head turned to right - interpretation: - nystagmus occurs after 2-20 seconds, unidirectional - fast component of the nystagmus is toward side of the affected posterior semicircular canal (the lower side when head is rotated) # Epley manoeuvre - designed to flush mobile otolithic debris out of ==posterior canal== and back into the vestibule - technique (for right ear eg fast beat of nystagmus to the right ) - patient upright with head to the right - rapidly moved to supine position with head hanging 45 deg to right (hallpike) - quickly rotate head 90 deg to the left so the right ear is up - patient rolls on the left side while head is also rotated left so that nose now faces the floor - rapidly return to sitting position facing left - repeat until no nystagmus ![[Pasted image 20240308173153.png| A through C. Dix-Hallpike position test; D, E. Epley Maneuver. Turn onto unaffected side. Hold position for 60 secs]] # Peripheral causes ## BPPV - most common - F > M - age 50-60 most common - deposits of otolithis in semicircular canal - posterior canal 85% of cases b/c gravity dependent History - sx tend to be episodic - sudden onsent - ooften on waking or after being supine - occurs with head turning, rolling on bed - duration < 1 min for each episode mgmt: - prochlorperazine 12.5mg IV, 5-10 mg TDS - promethazine 10-20 mg TDS - [[#Epley manoeuvre]] (see above) - D/c home if mild and mobilising OK ## vestibular neuritis and labyrinthitis - usually viral cause, HSV or zoster most likely - onset over hours, may follow flu-like illness - vertigo and nystagmus present at rest - usually horizontal with a small rotary or vertical component - resolves over days - 2 weeks - MRI w/ contrast may show focal enhancement in internal auditory canal - labryinthitis is rare, associated with unilateral conductive hearing loss mgmt: - prednisolone 1mg/kg up to 75 mg orally od for 5 days, then taper dose over 15 days and stop by 10 mg every 3 days - prochlorperazine or promethazine - no role for antivirals ## meniere disease - often men past middle age - decreased endolymph resprption - episodic vertigo > 30 min <24 hours duration - horizontal jerky nystagmus - *tinnitus* -- low pitched and unilateral mgmt: - restrict salt intake - avoid caffeine - +/- thiazides - HCTZ 25mg po daily - betahistine may increase blood supply to inner ear # central causes ## vertebrobasilar insufficiency - consider in older pts with isolated new onset vertigo without an obvious cause - more likely with h/o atherosclerosis - can occur with neck trauma - a/w [[Headache]] - neurologic sx include dysarthria, ataxia, weakness, numbness, [[Diplopia]] - may have internuclear opthalmoplegia - [[Cranial nerve palsies]] ## Cerebellar infarction - often due to medial branch of posterior inferior cerebellar artery (PICA); but branches of anterior inferior cerebellar artery (AICA) also supplies peripheral labryinth and central vestibular structures, so hearing loss may be present in this - 10% of cerebellar strokes present iwth vertigo and ataxia without other obvious cerebellar signs ## cerebellar haemorrhage - sudden onset of severe sx - headache, vomiting, ataxia ## occlusion of posterior inferior cerebellar artery (wallenberg syndrome) - aka lateral medullary infarction - posterior inferior cerebellar artery ischaemia - vertigo a/w significant neurologic complaints - nausea, vomiting - loss of pain and tem sensation on side of face ipsilateral to the lesion and opposite side of body - ataxia, hoarseness - horner syndrome (ipsilateral ptosis, [[miosis]], and decreased facial sweating) ## head trauma - sometimes called [Labyrinthine Concussion](https://pmc.ncbi.nlm.nih.gov/articles/PMC3936518/) - sx often begin shortly after head trauma - positional sx most common type after trauma, usually [BPPV](https://www.vestibularhealth.ca/blog/post-traumatic-bppv) - ***Post-traumatic BPPV*** more likely to re-occur, require multiple treatments, occur in both ears, and occur in multiple canals - Recurrent vestibulopathy is the most common cause of ***non-positional post-traumatic vertigo***. The incidence of Meniere's disease in the post-traumatic setting is not higher than found in the general population - usually mild nausea - very rare to be caused by [[Neck and spine trauma#Cerebrovascular trauma|vertebral dissection cerebrovascular trauma]] ## migranous vertigo ## multiple sclerosis # Drug therapy - prochlorperazine 12.5mg IV, 5-10mg po TDS - promethazine 10-20mg po TDS - improves sx, but may prolong duration of attacks -