Evaluation of the Dizzy Patient

Educational Objectives

The goal of this program is to improve the evaluation and management of dizziness. After hearing and assimilating this program, the clinician will be better able to:

1. Explain the difference between traditional and new approaches for evaluation of patients with dizziness.
2. Characterize triggered episodic vestibular syndrome.
3. Manage dizziness in patients using the Dix-Hallpike maneuver.

Summary

Dizziness: extremely common complaint; comes in different flavors; obtaining history and performing physical examinations for patients presenting with dizziness can be challenging; in majority of the cases, the cause of dizziness is benign; however, in some cases, the cause of dizziness can be serious

Background: in an emergency department setting, dizziness accounts for >4 million visits per year; stroke can be a worrying differential diagnosis for patients presenting with a primary complaint of dizziness and is observed in a minority of cases translating to 100,000 to 200,000 strokes per year; dizziness results in costly evaluations with most patients being admitted and undergoing computerized tomography resulting in an economic burden of 10 billion dollars per year

Misdiagnosis of patients with stroke presenting with dizziness: dizziness is a common presentation resulting in misdiagnosis of stroke; misdiagnosis of stroke presenting with dizziness is higher in comparison with other symptoms for which a stroke is missed; for patients presenting with dizziness as a primary complaint, it is difficult for clinicians to differentiate between the diagnosis of stroke and benign conditions

Traditional approach to diagnosis: patients are categorized into 4 types based on their history; 1) presyncope dizziness — patients describe feeling light-headed, feeling faint without loss of consciousness; clinicians typically perform a workup for syncope, ie, cardiac and noncardiac causes; 2) disequilibrium dizziness — patients describe a feeling of being off balance when walking or standing; the differential diagnosis includes polyneuropathy and other causes of central nervous system (CNS) dysfunction; 3) vertigo — patients describe a rotatory feeling or a sensation of movement even when stationary; the differential diagnosis for vertigo is specific; 4) unclassifiable (psychophysiologic) dizziness — patients describe a floating sensation; the condition is typically chronic; the symptoms are not consistent with those of the other categories

Challenges: obtaining a history from patients with dizziness can be difficult, leading to clinician frustration; patients with disorders of the vestibular system leading to vertigo often describe feeling faint sensation; patients with presyncope or orthostatic hypotension describe a “room spinning” sensation; over-reliance on symptom quality can lead clinicians away from the correct diagnosis; eye examination is an important part of making the diagnosis of stroke, and clinicians are often not taught good examination technique; the examination is frequently more important than risk factors for stroke

New approach to diagnosis of dizziness: “TiTraTE” stands for timing, triggers, and targeted examination; the timing of dizziness (onset, duration, evolution) and presence or absence of triggers can guide the differential diagnosis, which allows for a targeted examination and treatment plan; timing — can be used to categorize dizziness into episodic vestibular syndrome (EVS) or acute vestibular syndrome (AVS); EVS refers to transient or intermittent dizziness; symptoms last seconds to hours and can sometimes be prolonged; associated signs and symptoms include nausea, vomiting, nystagmus, and difficulty walking; consider the duration of each attack (attacks may be recurrent over days to weeks); patients with AVS are typically still dizzy on presentation; they have acute, persistent, and continuous dizziness with symptoms lasting hours to weeks; associated symptoms include nausea, vomiting, nystagmus, and postural instability; triggers — categorize vestibular syndrome into triggered (or provoked) EVS (t-EVS), spontaneous (unprovoked) EVS (s-EVS), provoked or triggered (caused by toxic exposure or trauma) AVS (t-AVS), and unprovoked (spontaneous) AVS (s-AVS)

Triggered EVS (t-EVS): episodes of dizziness are precipitated by a specific position or maneuver; the most common trigger is a change in head position (eg, standing up, turning head, rolling over); symptoms are not present between episodes; attacks usually last seconds to minutes; the examination should seek to reproduce the symptoms; the most common diagnoses are orthostatic hypotension and benign paroxysmal positional vertigo (BPPV); rare diagnoses (≈1%) include central paroxysmal positional vertigo (eg, cerebellar lesion)

BPPV: the most common vestibular cause of dizziness; arises from dislodging of the mobile crystalline structures located in the utricle of the vestibule into the semicircular canal, resulting in episodes of dizziness with changes in position of the head; patients experience repetitive, brief, triggered episodes of rotational vertigo lasting <1 min; the clinician should aim to reproduce the symptoms of BPPV to observe the nystagmus while testing in the office

Diagnosis and treatment of BPPV: the physician turns the patient's head 45 degrees toward the physician; the patient then lies down with the head hanging off the edge of the bed; this position results in movement of the crystals into the semicircular canal; this Dix-Hallpike maneuver can be used to elicit typical (upward and torsional) nystagmus toward the side of the ear that is down on the bed; this sensation builds up over 30 sec and then reduces over 1 min; patients with typical nystagmus can be treated with canalith repositioning; after the nystagmus sensation has passed, the patient’s head is turned 90 degrees so that head is positioned 45 degrees in the opposite direction resulting in falling of the crystals with gravity, leaving the semicircular canal; this movement results in the patient experiencing dizziness; the physician should wait for 1 min until the dizziness abates; this movement is repeated with the patient’s head facing down toward the bed; this results in the crystals falling out of the semicircular canal, ending up in the vestibular canal; rotational movement through a rapid turn of 90 degrees to one side can trigger horizontal nystagmus in rare cases; the etiology is peripheral in most cases, a central cause is very rare and is indicated by a purely downbeat or purely upbeat nystagmus that continues for ≈1 min; if nystagmus persists, brain magnetic resonance imaging (MRI) is indicated to identify a potential central cause

Spontaneous EVS: often benign; dizziness episodes last for minutes to hours with no identifiable triggers; depending on the cause, episodes can occur multiple times per day or more infrequently (eg, monthly); dizziness has typically resolved by the time of presentation (patients are in between episodes); because episodes cannot be provoked, the diagnosis is based on history; vestibular migraine is difficult to diagnose but likely the most common benign cause of s-EVS; other benign causes include Meniere disease, vasovagal presyncope, and panic attacks; the most concerning possibility is posterior circulation transient ischemic attack (TIA); vestibular migraine — causes vertigo and motion sensitivity

Diagnosis and treatment: the presence of a history can diagnose migraine and Meniere disease; for patients with an atypical history and vascular factors, perform a workup for posterior circulation TIA with vascular imaging

Postexposure AVS: the history is typically clear, with a temporal relationship between symptoms and trauma or drug exposure; patients may experience headaches or altered mental status; trauma can cause dizziness resulting from dissection of the vertebral artery; blunt head injury causes mechanical injury of the vestibular nerve; toxin exposure is often through drug or alcohol intoxication; ask about new prescriptions or changes in dosage of, eg, antidepressant, antipsychotic, and anti-epileptic agents, pain medications

Spontaneous AVS: persistent, continuous dizziness lasts for hours to weeks; patients are symptomatic at the time of assessment; symptoms are exacerbated by movement, and symptoms do not go away when patients stop moving; 10% to 20% of patients have stroke as the underlying cause of s-AVS; hearing loss may occur with occlusion of basilar artery or anterior inferior cerebellar artery; examination of eye movements is critical; the differential diagnosis includes vestibular neuronitis (the most common benign etiology), brainstem or cerebellar stroke, and nonvascular CNS etiologies (less common); vestibular neuronitis — is benign and self-limited

Neuroimaging: often not helpful for patients with stroke presenting with dizziness; CT has an extremely low yield and can provide false reassurance if normal; MRI is indicated if a central etiology is suspected, although MRI can give false-negative results in the hyperacute setting (ie, within 24-48 hr of onset); in this time frame, clinicians must rely on the examination to suggest whether symptoms are a result of stroke or vestibular neuronitis; HINTS is a mnemonic to describe the three key aspects of examination, ie, head impulse test, nystagmus, and test of skew; suspect stroke if any these 3 parameters are inconclusive for peripheral vestibular neuronitis (PVN)

Central vs peripheral nystagmus: nystagmus from PVN is horizontal-torsional and unidirectional; patients with a central etiology have bidirectional nystagmus (changes direction based on the direction of gaze); peripheral nystagmus typically subsides in a few days; central causes include stroke or centrally acting medication

Skew deviation: defined as ocular misalignment in the vertical plane (one eye is higher than the other); the alternating cover test can elicit this finding; this finding suggests a central cause

Head impulse test: the head thrust test assesses intactness of the vestibulo-occular reflex pathways; a normal result indicates a central etiology while an abnormal result indicates a peripheral etiology; the patient focuses on a target then rapidly turns their head 20 degrees horizontally; with an intact reflex, the eyes remain focused on the target; an abnormal result is loss of focus followed by a corrective saccade

Readings

Edlow JA, Gurley KL, Newman-Toker DE. A new diagnostic approach to the adult patient with acute dizziness. J Emerg Med. 2018;54(4):469-483. doi:10.1016/j.jemermed.2017.12.024; Kattah JC. Use of HINTS in the acute vestibular syndrome. An overview. Stroke Vasc Neurol. 2018;3(4):190-196. Published 2018 Jun 23. doi:10.1136/svn-2018-000160; Lempert T, von Brevern M. Vestibular Migraine. Neurol Clin. 2019;37(4):695-706. doi:10.1016/j.ncl.2019.06.003; Newman-Toker DE, Edlow JA. TiTrATE: A novel, evidence-based approach to diagnosing acute dizziness and vertigo. Neurol Clin. 2015;33(3):577-viii. doi:10.1016/j.ncl.2015.04.011.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Switzer was recorded at Seizures, Spells and Shakes: Neurology for the Non-Neurologist 2022, held July 7-9, 2022, on Kiawah Island, SC, and presented by the Medical College of Georgia at Augusta University. For information on future CME activities from this presenter, please visit https://mcg.cloud-cme.com/. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.25 CE contact hours.

Lecture ID:

IM702201

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.