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