Submitted by Rahul Gupta M.D.
HPI
- 43-year-old female p/w sudden onset vertigo, nausea, vomiting, and severe R sided headache 1 hour PTA
- HA is R sided, radiates into neck
- No weakness, numbness, tingling, speech changes
- Pt notes balance issues
- States that the vertigo is positional in nature.
Physical Exam
Vitals: BP 210/89, P 75, RR 18, SPO2 98%
- Neuro exam: Cn II-XII intact, motor strength normal, normal finger to nose, no nystagmus noted
- Gait was unable to be assessed secondary to vertigo
DDx
- subarachnoid hemorrhage, posterior circulation stroke, primary headache, vertebral artery dissection, peripheral vertigo
Case course
- A stroke alert was called
- CTA Head and neck demonstrated R vertebral artery occlusion. MRI demonstrated an acute infarct of the cerebellar vermis.
Pearls:
- Initial work-up of vertigo is stratifying between central and peripheral vertigo. The below table provides general patterns for both, but this is variable in nature.
- HINTS exam should be performed only when patient has persistent vertigo, nystagmus, and a normal neurological exam. When used correctly and performed appropriately, the HINTS exam has impressive sensitivity (100%) and specificity (96%) for posterior circulation stroke as compared to MRI
- See the HINTS exam in action here:
- The Dix-Hallpike maneuver can be performed if BPPV is in the differential. Dix-Hallpike is only 50-85% sensitive for BPPV. If positive, consider the Epley Maneuver for treatment.
- Consider teaching the patient the maneuver if they find relief after the Epley maneuver.
- Other treatments for peripheral vertigo include:
- 1st line: Diphenhydramine 25-50mg IM/IV/po q4hr, Meclizine 25mg po QID
- 2nd line: Diazepam 2-10 mg po/IV q4h-q8h, Lorazepam 0.5-2mg po/IM/IV q4h-q8h
References
- Barraclough K, Bronstein A. Vertigo. BMJ. 2009;339:b3493
- Kuo CH, Pang L, Chang R. Vertigo – part 1 – assessment in general practice. Aust Fam Physician. 2008;37(5):341-7
- Newman-Toker, D. E., Kattah, J. C., Alvernia, J. E., & Wang, D. Z. (2008). Normal head impulse test differentiates acute cerebellar strokes from vestibular neuritis. Neurology, 70(24 Pt 2), 2378–2385. https://doi.org/10.1212/01.wnl.0000314685.01433.0d
- Sacco RR et al. Management of Benign Paroxysmal Posi- tional Vertigo: A Randomized Controlled Trial. J Emerg Med. 2014 Apr;46(4):575-81
