Browse the corpus

General lnternal Medicine Vertigo Diagnosis The first important step is to distinguish central from peripheral causes with the HINTS exam or the Dix Hallpike maneuver. Diseases associated with central vertigo may be life threatening. Vertebrobasilar stroke is usually, but not always, accompanied by dysarthria, dysphagia, diplopia, weakness, ataxia or gait instability, or numbness. It should be considered in older persons with ASCVD risk factors. MS is suggested by relapsing and remitting neurologic abnormalities. Obtain an MRI of the brain for suspected central verl igo. The HINTS examination is indicated in patients with acute, persistent vertigo.

Vertigo Diagnosis The first important step is to distinguish central from peripheral causes with the HINTS exam or the Dix Hallpike maneuver. Diseases associated with central vertigo may be life threatening. Vertebrobasilar stroke is usually, but not always, accompanied by dysarthria, dysphagia, diplopia, weakness, ataxia or gait instability, or numbness. It should be considered in older persons with ASCVD risk factors. MS is suggested by relapsing and remitting neurologic abnormalities. Obtain an MRI of the brain for suspected central verl igo. The HINTS examination is indicated in patients with acute, persistent vertigo. STUBY T*B[E: HINTS (Head lmpulse, Nystagmus, and Test of Skew] Examination and lnterpretation Maneuver Method Reassuring Results (all pre- Concerning Results (any pre- sent suggests vestibular sent concerning for stroke) neuronitis) Head impulse test With the patient focusing on the Presence of catch-up saccades Absence of catch-up saccades examiner, the examiner slowly moves (consistent with peripheral (consistent with central cause the patient's head in either direction cause of vertigo) of vertigo) about 20 degrees and then rapidly rotates back to midline while assessing for catch-up saccades Nystagmus Examiner observes {or the presence Unidirectional nystagmus (fast- Bidirectional nystagmus (fast- assessment and directionality of nystagmus on phase contralateral ly) phase nystagmus alternating) lateralgaze Test of skew deviation Examiner alternates covering and Absence of vertical skew Presence of vertical skew (vertical deviation of uncovering each eye and assesses for one eye compared vertical adjustment or refixation with the other)

STUBY T*B[E: HINTS (Head lmpulse, Nystagmus, and Test of Skew] Examination and lnterpretation Maneuver Method Reassuring Results (all pre- Concerning Results (any pre- sent suggests vestibular sent concerning for stroke) neuronitis) Head impulse test With the patient focusing on the Presence of catch-up saccades Absence of catch-up saccades examiner, the examiner slowly moves (consistent with peripheral (consistent with central cause the patient's head in either direction cause of vertigo) of vertigo) about 20 degrees and then rapidly rotates back to midline while assessing for catch-up saccades Nystagmus Examiner observes {or the presence Unidirectional nystagmus (fast- Bidirectional nystagmus (fast- assessment and directionality of nystagmus on phase contralateral ly) phase nystagmus alternating) lateralgaze Test of skew deviation Examiner alternates covering and Absence of vertical skew Presence of vertical skew (vertical deviation of uncovering each eye and assesses for one eye compared vertical adjustment or refixation with the other) BPPV is the most common cause of acute, recurrent, and brief episodes of vertigo. It is diagnosed by findings on the Dix-Hallpike maneuver. This maneuver, like the HINTS exam, can differentiate BPPV from central causes of vertigo.

STUBY T*B[E: HINTS (Head lmpulse, Nystagmus, and Test of Skew] Examination and lnterpretation Maneuver Method Reassuring Results (all pre- Concerning Results (any pre- sent suggests vestibular sent concerning for stroke) neuronitis) Head impulse test With the patient focusing on the Presence of catch-up saccades Absence of catch-up saccades examiner, the examiner slowly moves (consistent with peripheral (consistent with central cause the patient's head in either direction cause of vertigo) of vertigo) about 20 degrees and then rapidly rotates back to midline while assessing for catch-up saccades Nystagmus Examiner observes {or the presence Unidirectional nystagmus (fast- Bidirectional nystagmus (fast- assessment and directionality of nystagmus on phase contralateral ly) phase nystagmus alternating) lateralgaze Test of skew deviation Examiner alternates covering and Absence of vertical skew Presence of vertical skew (vertical deviation of uncovering each eye and assesses for one eye compared vertical adjustment or refixation with the other) BPPV is the most common cause of acute, recurrent, and brief episodes of vertigo. It is diagnosed by findings on the Dix-Hallpike maneuver. This maneuver, like the HINTS exam, can differentiate BPPV from central causes of vertigo. STUDY TABLG: Common Causes of PeripheralVertigo Cause Findings BPPV Brief vertigo (10-30 s) and nausea associated with abrupt head movement (turning over in bed) Vestibular neuronitis Severe and longer lasting vertigo (days), nausea, and often vomiting Labyrinthitis Similarto vestibular neuronitis but with hearing loss

STUDY TABLG: Common Causes of PeripheralVertigo Cause Findings BPPV Brief vertigo (10-30 s) and nausea associated with abrupt head movement (turning over in bed) Vestibular neuronitis Severe and longer lasting vertigo (days), nausea, and often vomiting Labyrinthitis Similarto vestibular neuronitis but with hearing loss The Dix Hallpike maneuver can confirm the diagnosis of BPPV in most cases. STttBY TABLE: lnterpretation of Dix-Hallpike Maneuver Characteristic Peripheral Disease (BPPV vestibular Central Disease (brainstem or cerebellar neuronitis, labyrinthitis) stroke or tumor, MS) Latency of nystagmus (lag time between Delayed None maneuver and onset of nystagmus) Duration of nystagmus <l min >1 min Severity of symptoms Severe Less severe Fatigability (fi nd i n gs di minish with repetition ) Yes No Direction of nystagmus Unidirectional or mixed upbeat-torsional Variable (vertical or horizontal) Less common causes of peripheral vertigo: o Meniere disease (vertigo, hearing loss, tinnitus) . acoustic neuroma (hearing loss, tinnitus, unsteadiness, facial nerve involvement) . herpes zoster (Ramsay Hunt syndrome) 119