Dizziness

One of the 4 things: 1. Vertigo (50%) 2. Presyncope (4-14%) 3. Disequilibrium (1-16%) 4. Nonspecific dizziness (psychiatric disorder, hyperventilation or an unknown cause)

Acute vestibular syndrome (AVS)

rapid-onset dizziness that is continuous for > 24 hours

associated with nystagmus, unsteadiness of gait, nausea, vomiting, and intolerance to head movement

Cause

Benign conditions: Vestibular neuronitis and labyrinthitis.

Other causes: brainstem or cerebellar infarction or hemorrhage

Continuous nature for >24 hours excludes transient and intermittent conditions, such as benign paroxysmal positional vertigo, vestibular migraine, Meniere disease, and transient ischemic attack.

Vertigo

illusion of either personal or environmental movement

Symptoms

Frequently associated with nausea and made worse with head movement. Classically described as a spinning sensation, patients may report swaying, tilting, or other less abrupt movement.

Evauation

Once vertigo is suspected, the next important step is to distinguish central from peripheral causes --> Dix-Hallpike maneuver

Peripheral Vertigo

Benign paroxysmal positional vertigo (BPPV) - Most common

Why it happens?

Attributed to debris (canalithiasis), usually in the posterior semicircular canal, perturbing labyrinthine sensory receptors and resulting in the erroneous perception of angular head acceleration.

Vertiginous sensation is brief (10-30 seconds) and is precipitated by abrupt head movement

Nausea is a common accompaniment

Recurrence rates are high

Another cause is Vestibular neuronitis (or labyrinthitis, if hearing is affected)

may follow a viral syndrome that has affected the vestibular portion of cranial nerve VIII

Symptoms are generally more severe and of longer duration than in BPPV and may take longer to resolve

physical examination findings for both BPPV and labyrinthitis are similar; mixed upbeat-torsional nystagmus may occur, but no focal neurologic findings are present.

Less common causes

Vestibular schwannoma (acoustic neuroma)

aminoglycoside toxicity

Perilymphatic fistula (vertigo and hearing loss with history of straining or trauma)

herpes zoster

Meniere disease (classic triad of vertigo, hearing loss, tinnitus)

migraine

The Epley maneuver, also known as the canalith repositioning procedure, is an effective and safe treatment

Pharmacologic therapy

ineffective for cure but, as with other causes of peripheral vertigo, may be used for symptom relief

medications include centrally acting antihistamines (meclizine), vestibular suppressants (benzodiazepines), and antiemetic drugs

recommended that these medications be used only for short periods of time, as more prolonged use may suppress vestibular feedback and central compensation mechanisms

Vestibular rehabilitation therapy, delivered by trained physical or occupational therapists, is effective for patients with peripheral vertigo, especially if referred early

Central Vertigo

Stroke

Vertebrobasilar stroke is usually, but not always, accompanied by dysarthria, dysphagia, diplopia, weakness, or numbness

In a systematic review, focal neurologic signs were present in 80% of patients with stroke who presented with dizziness

Cerebellar infarct may present with gait or truncal ataxia or with vertigo alone

In one study, gait unsteadiness was reported in 55% of patients with central vertigo.

In cerebrovascular accidents located in the posterior fossa of brain, predominant symptom is dizziness in up to 70% of these strokes

Other causes

Brainstem encephalitis

Wernicke syndrome

Migraine

Multiple sclerosis, can present with vertigo, although a history of other relapsing and remitting neurologic abnormalities, including optic neuritis, is usually present.

Presyncope

Near loss of consciousness without loss of postural tone

Classic vertigo is absent

patients may have difficulty distinguishing “lightheadedness” from true vertigo

absence of loss of consciousness distinguishes presyncope from true syncope

Causes

result of a decrease in global cerebral perfusion, tachyarrhythmias, bradyarrhythmias, valvular heart disease, hypotension, or vasovagal reaction

In addition to dizziness, patients with presyncope may also experience nausea, warmth, or tunnel vision.

Disequilibrium

Unsteadiness, or sense of imbalance, with standing or walking

Nonspecific Dizziness and Chronic Subjective Dizziness