Vertigo in the Acute Care Setting
Vertigo in the Acute Care Setting
Author: Jeffrey A. Holmes, MD, Clinical Instructor, University of Vermont; Attending Physician, Department of Emergency Medicine, Maine Medical Center, Portland.
Peer Reviewer: Jonathan D. Lawrence, MD, Assistant Clinical Professor, Department of Emergency Medicine, Harborview Medical Center, Torrance, CA; Emergency Physician, St. Mary Medical Center, Long Beach, CA.
Introduction
Vertigo, a type of dizziness, is the illusion of motion, usually rotational motion, and is a common presentation to the emergency department (ED). It results from an acute unilateral vestibular lesion that can be peripheral (labyrinth or vestibular nerve) or central (brainstem or cerebellum). While the majority of causes are benign, it is imperative for the practitioner not to miss central causes of vertigo, such as cerebellar hemorrhage or infarction, that can be life-threatening and require immediate intervention.
Most cases of vertigo are from peripheral vestibulopathy and commonly include benign paroxysmal positional vertigo (BPPV), acute vestibular neuronitis, or labyrinthitis and Ménière's disease. They are associated with horizontal-rotary or horizontal nystagmus, auditory symptoms, mild gait imbalance, and lack of other neurologic abnormalities. Central vertigo, the most concerning, tends to present with more pronounced gait imbalance, continuous vertigo, and possibly other neurological signs such as diploplia, ataxia, dysarthria, and facial weakness. It is the primary priority of the acute care practitioner to differentiate central from peripheral vertigo and provide symptomatic relief for the patient. (See Table.)
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The objectives of this review are to:
Demonstrate the incidence of cerebellar stroke or transient ischemic attack (TIA) among patients who present with dizziness symptoms (DS);
Identify key features of patients with cerebellar ischemia that presents as pseudo-vestibular neuritis;
Demonstrate the utility of head computed tomography (CT) imaging in the patient with undifferentiated dizziness;
Discuss the limited utility of the bedside head impulse test to confirm peripheral vestibulopathy; and
Suggest a non-invasive, effective treatment for BPPV.
What is the Incidence of Stroke Among Patients Who Present to the ED with Dizziness Symptoms?
Source: Kerber KA, Brown DL, Lisabeth LD, et al. Stroke among patients with dizziness, vertigo, and imbalance in the emergency department: A population-based study. Stroke 2006;37: 2484-2487.
This observational study examined the incidence of stroke among patients presenting primarily to the ED with DS: dizziness, vertigo, or imbalance. During the study, 1,666 patients older than 44 years of age were identified, with the principal presenting complaint of dizziness (885), vertigo (665), imbalance (78), or more than one of these symptoms. Only 3.2% (53/1,666) of these patients were validated to have a stroke/ TIA by a neurologist. Of those with a validated stroke/TIA, the principal presenting complaint was vertigo in 18 cases and imbalance in 11 cases. Whereas 17% (9 of 53) of those with stroke/TIA had isolated DS (dizziness, vertigo, or imbalance without other stroke screening terms or accompanying neurologic signs or symptoms), only 0.7% (9 of 1297) of all patients presenting with isolated DS had stroke/TIA diagnosed. Isolated DS strongly predicted a nonstroke/TIA diagnosis (OR 0.05 [95% CI, 0.02-0.11]). Patients with vertigo did not have higher odds of stroke/TIA than those with dizziness (OR, 0.88 [95% CI, 0.39-1.97]).
Commentary
BPPV, one of the most common causes of vertigo, has its peak incidence between 50 and 70 years of age, an age that is also associated with an increased prevalence of stroke. In this study, the authors found that the rate of stroke/TIA in patients presenting to the ED with DS was low, especially among those with isolated DS. Of those with stroke that did present with isolated DS, imbalance was more associated with stroke/TIA than dizziness or vertigo. This seems to indicate that although vertigo and dizziness can be caused by acute brain stem or cerebellar stroke, the statistical association of these symptoms with stroke is less than the association of imbalance with stroke.
There are two limitations of this study. Most patients were not examined by a neurologist in the ED, and there was a lack of magnetic resonance imaging (MRI) in most patients, which increases the potential for missed subclinical strokes. However, this study reflects real-world experience for the evaluation of this acute neurological presentation seen in most EDs. This is bolstered by the fact that the catchment area of stroke cases for this surveillance study was strong and representative.
What Is the Yield of Head CT Imaging in the Acute Care Setting for Acute Dizziness or Vertigo?
Source: Wasay M, Dubey N, Bakshi R. Dizziness and yield of emergency head CT scan: Is it cost effective? Emerg Med J 2005;22:312.
Wasay and colleagues prospectively evaluated the diagnostic yield of head CT imaging in the evaluation of patients who presented to the ED with a chief complaint of acute dizziness or vertigo. Patients were excluded if they had a history of head and neck trauma, headache, altered mental status, recent head and neck surgery, or a new onset of focal neurological deficit. Of the 200 patients included in the study, 79 (40%) were men. Age range was 10-93 years (mean 68 years). CT showed normal findings in 105 patients (52%). Other lesions found but thought not to explain the patient's symptoms included diffuse brain atrophy, non-specific peri-ventricular white matter changes, chronic large-vessel distribution infarction, chronic lacunar infarction, chronic brain stem or cerebellar infarction, chronic subdural fluid collections, chronic postoperative changes, chronic watershed infarction, and the presence of a ventriculoperitoneal shunt. None of these findings were considered true positives. The average reimbursement for a non-contrast CT scan of the head was $300 and the total expense for all patients was $60,000. The diagnostic yield for the evaluation of acute vertigo and dizziness was zero.
Commentary
This small study is intriguing given the fact that it is not uncommon for the physician to order a head CT on a patient who presents with isolated, undifferentiated acute vertigo or dizziness to look for central pathology. While this is a much smaller number of patients than in the Kerber study, it has similar findings - central pathology in patients with isolated vertigo or dizziness is both uncommon and not easily found on immediate CT imaging. This also falls in line with our understanding of the CT scan's limitations for the detection of ischemia and posterior fossa lesions.
How Often Does Cerebellar Infarction Present as Isolated Vertigo?
Source: Lee H, Sohn SI, Cho YW, et al. Cerebellar infarction presenting as isolated vertigo: Frequency and vascular topographical patterns. Neurology 2006;67:1178-1183.
Lee and colleagues sought to determine the frequency of isolated cerebellar infarction mimicing vestibular neuritis (pseudo- VN), the pattern of clinical presentation, and the territory of the cerebellar infarction when it simulates VN. Two-hundred forty consecutive cases of isolated cerebellar infarction were evaluated by multiple experienced neurologists and diagnosed by brain MRI. Twenty-five of these patients (10.4%) had clinical features suggesting VN: acute spontaneous prolonged vertigo greater than 24 hours, nystagmus, and imbalance without other neurologic signs or symptoms. Almost all of these patients' infarcts (24/25) were in the territory of the posterior inferior cerebral artery (PICA), and almost all of these had only isolated spontaneous prolonged vertigo with imbalance as the sole manifestation of their cerebellar infarction. Seven patients had only mild postural imbalance, allowing them to still walk independently. None of the 24 patients with pseudo-VN due to PICA-territory infarcts had a positive head thrust test to either side. This study also found that 17 of 24 patients with PICA cerebellar infarction had normal vertebrobasilar arteries on MRA, consistent with an embolic mechanism for the stroke.
Commentary
Arguably the most important distinction for an acute care physician evaluating a vertiginous patient is to exclude a central cause, most specifically cerebellar infarction. The clinical syndrome of acute spontaneous and prolonged vertigo lasting days without any other neurologic or audiologic symptoms is commonly attributed to vestibular neuritis. This well-done study, however, reinforces the reality that similar clinical symptoms and signs occur with cerebellar stroke, and that the frequency of stroke is higher than previously thought. In this study, almost all the concerning cerebellar infarctions presenting with isolated spontaneous prolonged vertigo and gait imbalance were in the territory of the posterior inferior cerebellar artery (24 of 25). These infarcts are important to diagnose for two specific reasons: 1) They usually are caused by emboli originating from the heart or great vessels; and 2) They develop a mass effect in 10%-25% of cases, potentially leading to brainstem compression, hydrocephalus, cardiorespiratory complications, coma, and death.1-3
While gait instability was present in all these patients, it was mild enough in 7 of 24 patients (28%) to masquerade as a VN gait disturbance. While not commonly performed by most non-neurologists, a positive head thrust/impulse test (commonly used to identify a peripheral vestibulopathy and described below) was not present in any of these patients. While some patients with central pathology may still have a positive head thrust test, it is probably very rare for patients with peripheral vestibulopathy to have a negative test (as we will see in the next study reviewed).
The following conclusions drawn from this paper can be helpful to an acute care physician. For patients with spontaneous prolonged vertigo but without associated neurologic symptoms or signs, an MRI to exclude cerebellar infarction should be considered in older patients presenting with isolated spontaneous prolonged vertigo; any patient with vascular risk factors and isolated spontaneous prolonged vertigo who has a normal head thrust test; and any patient with isolated spontaneous prolonged vertigo who also demonstrates severe gait ataxia with falling from an upright posture.
Can the Head Impulse Test Help Differentiate Central Vertigo from Peripheral Vertigo?
Source: Newman-Toker DE, Kattah JC, Alvernia JE, et al. Normal head impulse test differentiates acute cerebellar strokes from vestibular neuritis. Neurology 2008;70:2378-2385.
In this study, Toker and colleagues tested the diagnostic accuracy of the horizontal head impulse test (h-HIT) of the vestibulo-ocular reflex (VOR) function in distinguishing acute peripheral vestibulopathy (APV) from stroke. Instead of evaluating the larger population of patients who were "acutely dizzy," they included only patients with acute vestibular syndrome and at least one stroke risk factor. This cross-sectional study was performed at an urban, academic hospital over a six-year period. All consecutive acute vestibular syndrome patients at high risk for stroke underwent structured examination (including h-HIT), neuroimaging, and admission. Stroke was confirmed by neuroimaging (MRI or CT). Of the 43 subjects enrolled, one had an equivocal h-HIT, 8/8 (100%) with APV had a positive h-HIT, while the majority of those with stroke had a negative h-HIT (n = 31/34, 91%). Three patients with stroke (9%) demonstrated a positive h-HIT.
Commentary
While this small study has several limitations, it makes an important point - a positive h-HIT test cannot be solely relied upon as evidence of APV as a cause for vertigo. This potentially useful bedside test of the VOR is positive when a subject is not able to visually fixate on an object when his head is rapidly, passively, and unpredictably rotated toward the side of the vestibular lesion. Instead of maintaining fixation during rotation, the patient with a positive test must correct his gaze shift when the head stops moving. Some have suggested a positive test confirms APV.3,4 This study, however, suggests the sign's absence may be more useful than its presence.
Is the Epley Maneuver Effective for the Treatment of Acute Benign Positional Vertigo?
Source: Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database of Systematic Reviews 2004; 2: CD003162; Fife TD, Iverson DJ, Lempert T, et al. Practice parameter: Therapies for benign paroxysmal positional vertigo (an evidence-based review): Report on the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2008;70;2067-2074.
Hilton and colleagues reviewed three studies that addressed the efficacy of the Epley maneuver for benign paroxysmal vertigo against a sham maneuver or control group. A total of 144 patients were included in these studies. Patients were diagnosed based upon a clinical history and examination including a positive Dix-Hallpike test. Individual and pooled data showed a statistically significant effect in favor of the Epley maneuver over controls for complete resolution of symptoms and conversion from a positive to negative Dix-Hallpike test. Pooled data for complete resolution of patient symptoms favored the treatment group with an odds ratio of 4.22 (95% CI 1.96 to 9.08). Pooled data for conversion from a positive to a negative Dix-Hallpike test favored the treatment group with an odds ratio of 5.12 (95% CI 2.30 to 11.38). They found no good evidence that the Epley maneuver provides long-term resolution of symptoms or is better when compared to other physical, medical, or surgical therapy for posterior canal BPPV.
The American Academy of Neurology's practice parameter by Fife also found that canalith repositioning maneuvers (CRP) seem to be an effective treatment for posterior canal BPPV. In this study, otoneurologists with expertise in BPPV and general neurologists with methodologic expertise reviewed and rated all relevant articles between 1966 and June 2006. They reviewed five randomized controlled trials including three hundred and five (305) patients. Four of these five studies used the Epley maneuver as their CRP, while the other used the Sermont maneuver. Patients were followed for resolution of symptoms and conversion from a positive to a negative Dix-Hallpike maneuver. Both pooled and individual data showed improvement to resolution of clinical symptoms and conversion to a negative Dix-Hallpike test more often with the treatment group than the sham group. Four meta-analyses and one systematic review also concluded that CRP and Sermont maneuver have significantly greater efficacy than no treatment in BPPV.
Commentary
BPPV is a common diagnosis for patients presenting to the acute care setting with vertigo. Posterior canal BPPV is confirmed with the Dix-Hallpike maneuver. Even patients with a typical history of posterior canal BPPV who have a negative Hallpike maneuver on the first occasion may demonstrate a positive test on retesting after a period of a few days. There is no great evidence to show that the Epley maneuver is better than other treatment modalities. While the Cochrane review's conclusion were based on only three studies that were small and limited by short follow-up time, it found the Epley maneuver to be safe, free of adverse effects, and effective for posterior canal BPPV (odds ratio of 5.12 [95% CI 2.30 to 11.38]). Only a small number of patients would have generally accepted contraindications for this procedure, including those with severe carotid stenosis, unstable heart disease, and severe neck disease (such as cervical spondylosis with myelopathy or advanced rheumatoid arthritis). It is a quick, noninvasive, easily learned, and cost-effective intervention we should provide to patients who suffer from significant symptoms. Numerous references abound on the Internet demonstrating this easily mastered procedure. (For example, see www.webmd.com/brain/liberatory-maneuvers-for-vertigo.)
After a Canalith Repositioning Maneuver, Should Patients Be Given Postural Restrictions?
Source: Casqueiro, JC, Ayala A, Monedero G. No more postural restriction in posterior canal benign paroxysmal positional vertigo. Otol Neurotol 2008;29: 706-709.
In this prospective double-blind consecutive case study, Casqueiro and colleagues sought to determine if postural restrictions after repositioning maneuvers for posterior canal BPPV improved patient symptoms. Two-hundred and seventy patients presented to a tertiary referral hospital and were diagnosed with posterior canal BPPV with clinical symptoms and a positive Dix-Hallpike test. All patients received a modified Epley maneuver. In the second group, patients were specifically instructed to wear a soft cervical collar and given postural restrictions such as not lying flat for 48 hours and avoiding lying on their affected sides until their follow-up visits. All of them were re-evaluated 10 days later, and they were followed up until their symptoms resolved. In the follow-up, a clinician queried patients regarding their subjective recovery and performed another Dix-Hallpike provocative test to analyze therapeutic efficacy.
The study found no statistical difference between the number of maneuvers needed to resolve symptoms between patients who restricted their movements (80.2 % of success with one maneuver) and those who did not (72.3%). Recurrence rate was not statistically different between groups (2.3 and 3.1%) and almost all patients felt better after treatment in both groups (97.1 and 98.9%).
Commentary
Almost all previous smaller studies have shown similar results to this well-designed prospective study - postural restrictions after the Epley maneuver are not useful in the resolution of patients' symptoms. The strengths of this study included the initial diagnosis by a neurologist with a positive Dix-Hallpike test and the excellent follow-up (only 23 patients total lost to follow-up). While this study was not designed for this endpoint, it is worthwhile to note their results support the use of the Epley maneuver. While some patients with BPPV can be expected to undergo spontaneous recovery, their study found that 76.5% of patients were asymptomatic and without nystagmus 10 days after only a single maneuver.
Which is Better for the Treatment of Vertigo in the ED - IV Lorazepam or Dimenhydrinate?
Source: Marill KA, Walsh MJ, Nelson BK. Intravenous lorazepam versus dimenhydrinate for treatment of vertigo in the emergency department: A randomized clinical trial. Ann Emerg Med 2000;36:310-319.
In this prospective, double blind, randomized clinical trial, Marill and colleagues set out to determine whether lorazepam was more effective than dimenhydrinate in relieving the symptom of vertigo in the ED. Patients were randomized to either 2 mg lorazepam IV or 50 mg dimenhydrinate. The predetermined primary outcome measurement was the patient's sensation of "vertigo with ambulation" at one hour and two hours after treatment. Secondary outcome measurements included vertigo while lying, sitting, and turning the head; ability to ambulate as judged by the enrolling physician; and sensation of nausea and drowsiness one hour and two hours after treatment per patient report or physician assessment. Seventy-four patients were enrolled. The patient's symptom of "vertigo with ambulation" decreased 1.5 units (95% CI 0-3.0) on average (on a 10-point scale) in the dimenhydrinate group. All other measures of vertigo also improved more in the dimenhydrinate group, although the differences were not statistically significant. At two hours after treatment, the patient's ability to ambulate was superior in the dimenhydrinate group (p=.001), and 17% (95% CI 2-36) more patients in this group were "ready to go home." Patients in the lorazepam group experienced a 1.8 unit (95% CI 0.2-3.4) greater increase in drowsiness two hours after treatment.
Commentary
There is a wide variety of pharmacotherapy used to treat patients thought to be suffering from peripheral vertigo, and no universally accepted drug of choice. In addition to antiemetics to control symptoms, antihistamines, anticholinergics, and benzodiazepines are three classes of drugs commonly used in the ED setting. This study seems to suggest that dimenhydrinate (an antihistamine) is less sedating, provides superior relief, and may shorten the length of ED stay when compared to lorazepam (a benzodiazepine). This study may have been slightly biased, however, based on the fact that patients randomly assigned to the lorazepam group were sicker based on their pretreatment symptoms and ability to ambulate. While the author could not find any definitive studies comparing the commonly used meclizine to other treatment modalities or placebo, it is possible that its antihistamine properties would give similar results as dimenhydrinate.
It is also worthwhile to point out that this study did not differentiate the presumed etiology of the patients' vertigo. Those with a clinical presentation consistent with vestibular neuritis (acute prolonged vertigo with nausea, ataxia, nystagmus, and a viral prodrome) may also benefit from a short course of steroids; however, the data to support this is from small studies.6-8
Summary
Vertigo is a common but high-risk complaint in the ED. While the majority of patients who present to the ED have a peripheral cause, it is imperative for the practitioner not to miss central causes such as cerebellar hemorrhage or infarction. A thorough history and physical exam, focusing on a detailed neurologic exam, will help discriminate most cases. Specific physical exam tests that are not commonly used, but may be helpful, are the Dix-Hallpike test (a positive test is considered diagnostic for BPPV) and the horizontal head impulse test (a negative test implying the absence of a peripheral vestibulopathy as the cause of the patient's symptoms).
However, even if a thorough history and physical exam suggest peripheral vertigo, some patients will still have a potentially life-threatening central cause. The following principles will help the practitioner diagnose these elusive presentations:
The clinical syndrome of acute spontaneous and prolonged vertigo lasting days without any other neurologic or audiologic symptoms is commonly attributed to vestibular neuritis. Some cerebellar infarcts, however, may present similarly.
For patients with spontaneous prolonged vertigo without associated neurologic symptoms or signs, an MRI to exclude cerebellar infarction should be considered in older patients presenting with isolated spontaneous prolonged vertigo; any patient with vascular risk factors and isolated spontaneous prolonged vertigo who has a normal head impulse test; and any patient with isolated spontaneous prolonged vertigo who also demonstrates severe gait ataxia with falling from an upright posture.
A non-contrast head CT for the patient who presents to the ED with acute dizziness or vertigo is usually nondiagnostic. Other than hemorrhagic stroke (which is not as subtle a presentation), CT head imaging rarely reveals a central cause of vertigo such as CVA/TIA, even when these are the causative conditions. The acute care practitioner who has a strong suspicion should obtain an MRI of the brain.
Some have advocated that a positive head impulse test confirms peripheral vertigo. While the majority (if not all) of patients with a peripheral vestibulopathy will have a positive test, so will some patients with cerebellar CVA.
Of those patients with stroke who did present with isolated DS, imbalance was more associated with stroke/TIA than dizziness or vertigo. The imbalance, however, can be mild enough in 28% of patients to masquerade as a VN gait disturbance.
The following principles can help you effectively treat the symptoms of peripheral vertigo:
The Epley maneuver is a quick, noninvasive, easily learned and cost effective intervention for BPPV that we should provide and teach to our patients.
Postural restrictions after CRP are not useful in the resolution of patient's BPPV symptoms.
Compared to lorazepam, dimenhydrinate may be less sedating, provide superior relief of vertigo and may shorten the length of ED stay.
References
1. Macdonnell RA, Kalnins RM, Donnan GA. Cerebellar infarction: natural history, prognosis, and pathology. Stroke 1987;18:849-855.
2. Amarenco P. The spectrum of cerebellar infarctions. Neurology 1991;41:973-979.
3. Kase CS, Norrving B, Levine SR, et al. Cerebellar infarction: clinical and anatomic observations in 66 cases. Stroke 1993; 24:76-83.
4. Halmagyi GM. Diagnosis and management of vertigo. Clin Med 2005;5:159-165.
5. Halmagyi GM, Curthoys IS. A clinical sign of of canal paresis. Arch Neurol 1988;45:737-739.
6. Strupp M, Zingler VC, Arbusow V, et al. Methylprednisolone, valacyclovir, or the combination for vestibular neuritis. N Engl J Med 2004;351:354-361.
7. Kitahara T, Kondoh K, Morihana T, et al. Steroid effects on vestibular compensation in human. Neurol Res 2003;25:287-291.
8. Ariyasu L, Byl FM et al. The beneficial effect of methylprednisolone in acute vestibular vertigo. Arch Otololaryngol Head Neck Surg 1990;116: 700-703.
Vertigo, a type of dizziness, is the illusion of motion, usually rotational motion, and is a common presentation to the emergency department (ED).Subscribe Now for Access
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