Vertigo

In patients presenting with dizziness, it is vital to establish whether the patient is describing true vertigo, pre-syncope or unsteadiness. Vertigo is a sensation of abnormal spinning movement of the patient or their surroundings.

From an emergency perspective, it is important to differentiate between:

• Peripheral vertigo (caused by lesions of the vestibular nerve and inner ear, e.g. BPPV, labyrinthitis, Meniere’s disease, acoustic neuroma).
• Central vertigo (caused by lesions of the CNS, e.g. cerebellar or brainstem stroke, vertebro-basilar insufficiency, multiple sclerosis, drug toxicity).

History

Is the vertigo continuous or intermittent?

• Positional, intermittent vertigo is suggestive of BPPV.
• Continuous vertigo, also known as acute vestibular syndrome is suggestive of acute peripheral vestibulopathy – vestibular neuritis, labyrinthitis, or cerebellar lesion.

Duration of onset?

• Sudden onset: BPPV, stroke.
• Gradually progressive: tumour, demyelination.

Associated symptoms?

• Hearing loss, tinnitus suggests vestibular neuronitis / labyrinthitis / Meniere’s.
• Fever and ear pain suggests bacterial labyrinthitis.

Red flags?

• Sudden head, neck or facial pain (carotid or vertebral dissection, intracranial haemorrhage).
• Syncope.
• Visual loss.
• Elderly patient.
• Multiple risk factors for ischaemic stroke (AF, diabetes, hypertension, CCF, previous CVA).

Examination

The physical examination should aim to identify cerebellar signs, which are tested as follows:

• Assess for scanning speech (patients with cerebellar lesions break complex phrases into individual syllables): e.g. ask the patient to repeat “the British Constitution”, “42 West Register Street”.
• Nystagmus (see below).
• Pronator drift: eyes closed with arms outstretched and supinated – a slow upward drift in one arm suggests a contralateral cerebellar lesion.
• Rebound test: as above, the patient is asked to keep their arm in position whilst the examiner pushes downwards then suddenly releases. In cerebellar disease, there is loss of antagonist muscle response and the limb shoots above the original position).
• Finger-to-nose test, or heel-to-shin test (looking for past-pointing or intention tremor).
• Rapid alternating movements e.g. flipping one hand on the other or rapid foot tapping. (Slow or irregular movement, a.k.a. dysdiadochokinesia suggests a cerebellar lesion).
• Gait or truncal ataxia – cerebellar disease causes broad stance, staggering, and the patient may fall to side of lesion.

Presence of cerebellar signs should prompt further evaluation for posterior circulation stroke, preferably with MRI.

A good video summary of cerebellar examination is found here.

The HINTS exam

In patients with continuous vertigo and otherwise normal neurological examination, the HINTS exam should be performed. This is because abnormalities in vestibulo-ocular reflex may be the only abnormal neurological finding in patients with cerebellar infarcts. The HINTS exam appears more sensitive for stroke than early MRI. (Kattah et al. 2009) It consists of three components: Head Impulse test, Nystagums and Test of Skew. If any portion indicates a central cause, further evaluation for stroke or central pathology is indicated (e.g. neurology referral +/- MRI).

Horizontal head Impulse test

The Head Impulse Test assesses the vestibulo-ocular reflex. With the patient sitting opposite the examiner and looking at the examiner’s nose, the patient’s head is rotated laterally 20-30 degrees, then rapidly returned to midline. The patient’s eyes are observed for “overshoot” and saccadic adjustment (eyes continue to travel in the direction of rotation then correct suddenly) – this constitutes a positive test.

• An abnormal (positive) test as indicated by overshoot + corrective saccades is suggestive but not conclusive of peripheral vertigo.
• A normal (negative) test strongly indicates a central cause.

Positive head impulse test video can be viewed here. 

Nystagmus

Nystagmus is assessed by observing the patient’s gaze with head stationary. Initially looking straight ahead, then following the examiner’s finger as it is moved 30 degrees right, left, up and down. Nystagmus at extremes of gaze is normal and is referred to as physiological nystagmus. Pathological nystagmus is characterised by alternating slow eye movement in one direction (smooth pursuit) with a fast (saccadic) movement in the opposite direction. The direction of nystagmus is defined by the direction of the quick phase.

Nystagmus is often absent in central vertigo.

Typical characteristics of nystagmus are as follows:

Test of Skew

Also known as the alternating cover test, it tests for vertically disconjugate gaze. With the patient sitting opposite the examiner and looking at the examiner’s nose, one of the patient’s eyes is covered (preventing the covered eye from fixating). The hand is rapidly removed; an eye that is vertically misaligned can be seen to re-align. This is abnormal and suggestive of a central cause.

Conditions causing Peripheral Vertigo

Benign positional vertigo (BPPV)

• Most common cause of vertigo. Female predominance, greatest incidence aged 50-60.
• Due to otoliths in semicircular canal.
• Usually sudden onset with brief episodes of positional vertigo lasting approximately 30 seconds that resolve if no further motion.
• No associated hearing loss.
• Horizontal nystagmus beats predominantly towards affected ear following brief delay, non-sustained and fatiguable.
• Positional manouvers such as Epley may result in rapid recovery - see video here.
• Treatment is otherwise supportive with anti-emetics, e.g. prochlorperazine 5-10mg po t.i.d.
• Also see ECI Benign Paroxysmal Positional Vertigo (BPPV) Patient Factsheet.

Vestibular Neuronitis

• Likely viral cause (HSV or zoster), may follow ‘flu-like illness.
• Onset over hours, resolving over days.
• Vertigo occurs with head stationary.
• Horizontal nystagmus at rest.
• Antiemetics / antihistamines.
• Corticosteroids may offer some benefit (see Fishman et al. 2011).

Labyrinthitis

• May be viral or bacterial (from otitis media).
• Similar to vestibular neuronitis + tinnitus or hearing loss.
• Toxic-appearing patients may require admission for IV antibiotics.

Meniere’s Disease

• Often occurs in men past middle age, due to decreased endolymph resorption.
• Causes episodes of vertigo lasting 30 mins – 24hrs.
• Horizontal, jerky nystagmus associated with nausea, vomiting and sweating.
• Low pitched unilateral tinnitus.
• Management involves restricting salt and caffeine intake, thiazide diuretics.

Further References and Resources

Fishman JM, Burgess C, Waddell A. (2011) Corticosteroids for the treatment of idiopathic acute vestibular dysfunction (vestibular neuritis). Cochrane Database of Systematic Reviews, Issue 5.

Kattah JC, et al. (2009) HINTS to Diagnose Stroke in the Acute Vestibular Syndrome, Stroke, Vol. 40, pp. 3504-3510.