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Vertigo - Bedside Diagnosis
Sandeep Rai*, Pawan Ojha**, Abhijit K Korane***
 

Abstract
Vertigo is a common symptom in clinical practice, attributed to various aetiological factors such as peripheral and central aetiology. Majority of cases with Vertigo are as a result of peripheral aetiology, although less commonly Vertigo presenting in the Emergency department can be as a result of more serious causes such as brainstem and cerebellar ischaemia/haemorrhage making a diagnostic dilemma. We present an article giving an overview to approach to a patient with Vertigo, with its common causes and approach to the patient of Vertigo.

 

Vertigo is defined as a hallucination of movement of Self or of the Surrounding. Vertigo is a subset of Dizziness which is a common non-specific presenting complaint used by the patients to describe different subjective sensations, including vertigo. Drachman proposed four categorizations of Dizziness based on clinical characteristics:1

  1. Disequilibrium: - caused by motor dysfunction that impairs balance and gait “Dizziness of feet”.
  2. Presyncope: - a sense of impending loss of consciousness due to hypoperfusion of brain or metabolic causes such as hypoglycaemia.
  3. Lightheadedness: - which includes nonspecific symptoms related to multiple sensory disturbances, side effect of medications that alter the sensorium and psychiatric disturbances.
  4. Vertigo: - a sensation of movement due to disorder of labyrinth or its central connection.

Vertigo can be easily differentiated from other causes of dizziness by a “sensation of motion”. The sensation can be subjective (patient is moving) or objective (environment is moving). In Dizziness due to Orthostatic Hypotension or Arrhythmias patient experiences giddiness, presyncope or darkening of vision but there is no sensation of motion. The sensation of motion effectively removes the differential diagnosis from Cardiovascular into realm of specific Neurological disturbance.

The most common cause of pathologic vertigo is Vestibular dysfunction. The vertigo is frequently accompanied by nausea, jerky nystagmus, postural unsteadiness and gait ataxia.

Common cause of vertigo:-

Peripharal Aetiology
  1. Benign positional vertigo,
  2. Vestibular neuronitis,
  3. Acute labyrinthitis,
  4. Meniere’s disease.
  5. Toxins: - aminoglycosides, alcohol.
Central Aetiology
  1. Brainstem and/or Cerebellar (Ischaemia/Haemorrhage)
  2. Vertebrobasilar Insufficiency (TIA/Infarct)
  3. Multiple Sclerosis.
  4. Basilar artery Migraine.
Uncommon Causes of Vertigo

Acoustic neuroma, Post-traumatic vertigo, Peri-lymph fistula, Autoimmune inner ear disease, Syphilitic labyrinthitis.

Common causes of peripheral vertigo:-

a) Benign positional vertigo (BPV) : It is one of the most common types of vertigo.1,2 It is produced by sudden change in head position and lasts for few seconds. The most prominent symptoms are vertigo that occur when the patient in the bed rolls into lateral position, or the patient is looking upwards (bringing down an object from high shelf) or turning towards the affected ear in the bed. Each episode lasts for 10-20 seconds and can be associated with nausea. The patho-physiology of BPV includes presence of free floating particulate matter within the posterior semicircular canal of the vestibular labyrinth.3,4 Diagnosis is confirmed by Dix-hall pike manoeuvre.

b) Acute labyrinthitis :This is a common cause of acute onset severe vertigo associated with nausea and sensorineural hearing deficit. Aetiology is usually viral and half of the patients complain of flu like illness within preceding two weeks. Although vertigo can last for several days, but it usually resolves within a week. With fixed unilateral defect, Central compensatory mechanisms ultimately diminish the vertigo. However, transient episodes of Dizziness may last months following the acute episode. Acute bilateral labyrinthine dysfunction is usually the result of Drugs (aminoglycosides) or Toxins (alcohol).

c) Vestibular Neuronitis : This condition causes sudden onset acute severe vertigo but no auditory symptoms. Aetiology is usually viral infection in young patients causing injury to the vestibular apparatus, but in older patients vascular causes are likely. It is also termed as acute vestibular failure. The single episode of severe vertigo may last one or two days but patients may remain symptomatic for months.

d) Meniere’s Disease : The disease presents as episodic attacks of spontaneous vertigo associated with vomiting, tinnitus, and unilateral hearing loss and a sensation of fullness in the ear. Attacks can last for minutes to hours. Pathogenetic mechanisms have been linked to impaired endolymphatic filtration and excretion and increase in the endolymphatic fluid with distension of labyrinth. Tinnitus (low tone, roaring or blowing in quality), fluctuating low frequency sensorineural hearing loss are characteristic of this disease.8

Central Causes of Vertigo

A central cause of vertigo is usually suspected in elderly patients who have risk factors for vascular disease. Brainstem is dense with structures that sub serve many neurological functions. Brainstem TIA or stroke that cause vertigo also have associated long tract motor, sensory or cranial nerve nuclei involvement referred to as "Neighbourhood signs”.2

Most patients with cerebellar infarction have lateralizing signs such as dysmetria, past-pointing, dysdiadochokinesis.

Vertigo due to ischaemia in distribution of Vertebrobasilar circulation present with diplopia(vertical or horizontal), dysarthria, bifacial numbness and weakness or numbness of part or all of one or both sides of the body (i.e. disturbances of long motor or sensory tract bilaterally).

Vertigo among others is a prominent symptom of multiple sclerosis and migraine.5 Vertigo may be presenting symptom in 5% of patients but eventually develops in 50% of patients with multiple sclerosis. In patients with psychogenic vertigo the dizziness does not fit in any recognizable symptom complex and is present for years. Vertigo is usually continuous, never associated with nystagmus and not reproduced by any manoeuvres like Dix-hall pike or valsalva or hyperventilation.
Approach to A Patient with Vertigo

A detailed history including onset, duration, associated symptoms and detailed otological, neurological examination including tests for hearing, nystagmus, ataxia and long tract sensory and motor signs give a clue to diagnosis.

Following are the important points in History and Examination:-

1) Vertigo? : First confirm the symptoms of patient are vertiginous in nature and not suggestive of Presyncope or Non-Vestibular Dizziness. Is there a sensation of Motion or not?

2) Spontaneous or Provoked? : Is the vertigo spontaneous or provoked by changes in the head position (BPV), Noise induced Vertigo (Tullio phenomenon) occurs in superior semicircular canal dehiscence and pressure induced vertigo (valsalva, straining, exercise) suggest perilymph fistula.

3) Onset : Sudden onset vertigo can be both due to peripheral and central causes, however onset of central vertigo is usually spontaneous not related to position of head, whereas that of peripheral cause like BPV is clearly associated with sudden change in position of head and occurs after a latent period of 10-20 seconds after change in head position. Vertigo that is associated with labyrinthitis and neuronitis comes slowly over hours in contrast to that of stroke (central cause) in which vertigo starts suddenly. The character of nystagmus and “Neighbourhood signs” helps to Differentiate Peripheral from Central causes.

4) Duration :
Vertigo lasting for Seconds : Suggest Benign Positional Vertigo.
Vertigo lasting for Minutes : Suggest Transient cerebrovascular Ischaemia. (Posterior circulation TIA)
Vertigo lasting for Hours : Suggest Meniere’s Disease.
Vertigo lasting for Hours-days : Suggest Vestibular neuronitis or posterior circulation stroke.

5) Recurrent or single episode?

Recurrent Episodes of Vertigo (Peripheral cause) : Vertigo lasting minutes to hours can be due to Meniere's Disease which is associated with prolonged vertigo with associated deafness and tinnitus. Migraine is usually associated with typical headache with a positive family history and usually a history of BPV in childhood. Autoimmune inner ear disease closely resembles Meniere’s disease but a raised E.S.R and positive anti-nuclear factor helps in the diagnosis.

Recurrent Episodes of Vertigo (Central causes) : Vertebrobasilar insufficiency can present as recurrent vertigo lasting minutes with concomitant motor, sensory, visual, cranial nerve and cerebral signs.

Single Episode of Prolonged Vertigo (Peripheral causes) : Acute labyrinthitis/ vestibular neuronitis (Peripheral), vertigo lasts for hours associated with Otological symptoms but no Neurological symptoms. Patient if encouraged to stand without support and walk, can do so, however in Central lesions which includes brainstem or cerebellar (ischaemia/haemorrhage) usually are associated with ”Neighbourhood Signs” and patient usually cannot walk unaided.

Recurrent Positional Vertigo : It is usually due to BPV, Post-traumatic vertigo or Psychogenic vertigo. All types of vertigo whether central or peripheral are worsened with movement of head, but only some are provoked by specific head positions like BPV.

6) Otological symptoms : Associated otological symptoms such as deafness, tinnitus suggests peripheral vertigo although it may rarely occur with central lesions also.

7) Nystagmus : Direction of Nystagmus is defined by direction of the fast phase. Testing for the direction, latency, fatigue and decrease with fixation can help to characterize nystagmus into peripheral or central types.

Peripheral Nystagmus is easily fatigued and is decreased or even eliminated at times with visual fixation. Hence it is always advisable to check nystagmus avoiding visual fixation i.e. ask the patient to vaguely stare into distance and then ask him to look 45 degree to left and then to the right and do not instruct to follow examiner's finger as per usual testing technique. Peripheral nystagmus is usually horizontal (horizonto-rotatory), but is never vertical or pure torsional.

Central Nystagmus is present spontaneously at rest, does not fatigue and unaffected by visual fixation. It may change beat direction in different directions of gaze and may be purely vertical or horizontal and it persists for many weeks in contrast to peripheral vertigo which usually remits in few days to a week and is characteristically unidirectional.

To see nystagmus better eyes can be magnified by asking patient to wear high diopter reading glasses called as Frenzel glasses.

8) Special Manoeuvres : Certain Special Manoeuvres help in diagnosis of Vertigo.

  1. Dix-Hallpike Test : The patient sits upright with head rotated 30-40 degrees laterally. Patient is then rapidly moved in supine position with head hanging on the end of the examination table. Patient is then examined for Nystagmus. Next the patient's head is turned to opposite side. A characteristic peripheral nystagmus appears in cases with BPV after a latency of few seconds and both vertigo and nystagmus fatigue with repeated testing in BPV.
  2. Head Thrust Test : Also called the Vestibulo-Ocular Reflex or the Head Impulse Test involves asking the patient to fixate on the examiner's nose. The examiner then rotates the patients head to either side 10-20 degrees. The normal response is for the eyes to remain fixated on examiner’s face, moving smoothly to keep up with head rotation. In unilateral Vestibular deficit instead of eyes remaining fixed on the target, they make discernible saccades, or jumps, back to the target, and with quick corrective eye movements. This test is positive in peripheral causes of vertigo (Vestibular Neuritis).

Table 1 shows Clinical features to differentiate peripheral from central type of vertigo.

A comfortable clinical distinction between peripheral and central causes of vertigo can be made in most cases based on proper History and Examination, as described above.

Acute vertigo in Emergency Department

A crucial aspect of management in Emergency department is to differentiate acute vertigo associated with acute stroke syndrome from that due to peripheral causes.

  • In a patient who presents in Emergency with sudden onset headache, acute vertigo and inability to ambulate, cerebellar haemorrhage is a very likely possibility.
  • Most cases of Central vertigo present with “Neighbourhood signs”, however Emergency Physician should be vigilant not to miss a rare Central cause of Isolated vertigo (with no “Neighbourhood signs”) which may progress to stroke, for example,
    1. Vertigo (Isolated) is a prominent and sometimes the only symptom in Inferior Cerebellar Infarct due to thrombosis of posterior inferior cerebellar artery (PICA). Characteristic Central type of Nystagmus and Inability to stand and ambulate unaided, favours a diagnosis of Cerebellar involvement. The importance of diagnosing these small Cerebellar infarcts is that majority are Cardio-embolic in cause and may need urgent anti-coagulation therapy.
    2. Contrary to traditional teaching rarely, isolated vertigo without other neurological signs can also be a symptom of vertebrobasilar insufficiency (TIA).10,11 Vertigo may precede the development of more obvious “Neighbourhood Signs” or symptoms, or they may appear at the time when Infarction occurs.12,13 19% patients with Vertebrobasilar Insufficiency report at least one episode of Isolated Vertigo occurring 1.5 yrs. to two days before development of multiple symptoms.14
  • Most cases of peripheral vertigo are associated with tinnitus and deafness, however rarely in elderly patients with vascular risk factors, internal auditory artery a branch of anterior inferior cerebellar artery can produce infarction of labyrinth and semicircular canal and can present with Vertigo, tinnitus, hearing loss i.e. a Central lesion mimicking a Peripheral cause. Months later a full blown picture of AICA occlusion with “Neighborhood Signs” may appear.2,6,10,11
  • Peripheral localization of vertigo cannot be confirmed with certainty in Emergency situations and a Central cause must always be excluded with detailed Neurological examination and Brain imaging if necessary
References
  1. Drachmann DA. A 69 yr man with chronic dizziness. JAMA 1998; 280:2111-8.
  2. Hoston JR, Baloh RW. Acute vestibular syndrome. N Engl J Med 1998;339:60-685.
  3. Lampert T, Gresty MA, Bronstein Am. Benign positional vertigo:Recognition and treatment. Br Med J 1995;311:489-491.
  4. Welling DB, Parnes LS, oBrein B, Brackmann DE. Particulate matter in posterior semicircular canal. Laryngoscope 1997;107:90
  5. Neuhauser H, Leopold M, von Bevern M, Arnold G, Lempert T. The interrelations of migraine, vertigo and migraneous vertigo. Neurology 2001;56:43-431.
  6. Grad A, Baloh RW. Vertigo of vascular origin; clinical and electronystagmographic features in 84 cases. Arch Neurol 1989;46:281-4.
  7. Joseph M. Furman, Stephen P. Cass. NEJM 1999; 341 : 1590-96.
  8. RK Garg, S.Jain Approach to diagnosis and management. JAPI 1998; 46 : 2.
  9. Baloh RN. Vestibular Neuronitis. NEJM 2003; 348 : 1027-32.
  10. Fisher CM. Vertigo in cerebrovascular disease. Arch Otolaryng 1967; 85 : 529-34.
  11. Baloh RW. Vertebrobasilar insufficiency and stroke. Otolaryngoe head and neck surgery. 1995; 112 : 114-7.
  12. Gomez CR, Cruz-Flores S, Malkoff M, Saucer CM, Bruch CM. Isolated vertigo as a manifestation of vertebrobasilar insufficiency. Neurology 1996; 47 : 94-7.
  13. Huang CS. Vertigo of central origin. Proc R Soc Med 1962; 55 : 364-70.
  14. Grad A, Baloh RW. Vertigo of vascular origin: Clinical and electronystagmographic features in 84 cases. Arch Neurol 1989; 46 : 281-4.
 
* Associate Professor and Unit Head; **Hon. Lecturer and Consultant Neurologist; ***Post Graduate student, Department of Medicine, MGM Medical College and Hospitals, Navi Mumbai.
 
 

USE LONG NEEDLES TO IMMUNISE INFANTS

Long (25 mm) needles are best for immunising children aged 2,3 and 4 months, say Diggle and Deeks. They randomised almost 700 healthy infants who had been vaccinated with a combined diphtheria, pertussis, tetanus, and Haemophilus influenzae type b vaccine and a meningococcal C vaccine at ages 2, 3, and 4 months to either a long wide needle (25 mm, 23 gauge), a short marrow needle (16 mm, 25 gauge), or a long narrow needle (25 mm, 25 gauge). Long needles significantly decreased local reactions after each dose, and immunogenicity was comparable between long and short needles, independent of the width.

BMJ, 2006; 333 : 571.
 
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