#49: Vertigo and Dizziness: How to Treat, Who to Send Home and Who Might Have a Stroke
Jul 24, 2017
auto_awesome
Joining the discussion are Dr. David Newman-Toker, an esteemed international expert in neurology, ophthalmology, and otolaryngology, and Dr. Cyrus Askin, a recognized contributor to the medical field. They unravel the complexities of diagnosing dizziness and vertigo, exploring critical tests like the Dix-Hallpike and HINTS exam. The conversation highlights how to distinguish strokes from other causes of dizziness and the roles of medical therapy and vestibular rehab. Listeners will gain practical insights for improving patient assessments and treatment strategies.
Differentiating dizziness types, such as episodic and acute vestibular syndrome, is crucial for accurate diagnosis and treatment.
The HINTS examination is a vital tool in the emergency setting, providing more accuracy than early MRI scans to detect stroke.
Management of dizziness varies by diagnosis, with techniques like the Epley maneuver and vestibular rehabilitation enhancing recovery outcomes.
Deep dives
Understanding Dizziness and Its Classifications
Dizziness is a complex symptom that can arise from various underlying conditions. It is critical to categorize dizziness into specific types such as episodic, acute vestibular syndrome, and chronic vestibular syndrome based on the duration and triggers of symptoms. Episodic dizziness typically presents as brief episodes triggered by specific head movements, while acute vestibular syndrome is characterized by persistent symptoms lasting more than 24 hours. Chronic vestibular syndrome involves continuous symptoms that may have fluctuating intensity over a longer duration, and understanding these distinctions aids in accurate diagnosis and treatment.
The Role of the HINTS Examination
In evaluating patients with acute vestibular syndrome, the HINTS examination is an essential bedside tool for distinguishing between peripheral and central causes of dizziness. This exam assesses head impulse, nystagmus, and skew deviation to determine the integrity of the vestibular and central nervous systems. A pivotal finding during the HINTS exam is abnormal head impulse testing paired with unidirectional nystagmus, which can indicate vestibular neuritis over acute stroke. The accuracy of an adequately performed HINTS examination can surpass that of early MRI scans, making it a critical skill for clinicians in emergency settings.
Differential Diagnosis and Importance of History Taking
When assessing a patient with dizziness, a comprehensive history focused on timing, triggers, and associated symptoms is vital for appropriate diagnosis. Different vertiginous conditions have varying potential triggers and manifestations; for instance, benign paroxysmal positional vertigo (BPPV) often triggers symptoms from specific head positions while vestibular migraine can cause episodes without clear positional triggers. Being aware of these nuances allows clinicians to streamline their diagnostic approach and avoid unnecessary investigations. Furthermore, understanding a patient's history can facilitate identifying high-risk cases that require immediate intervention, such as strokes.
Management Strategies for Dizziness
Management of dizziness largely depends on the underlying diagnosis, with specific maneuvers such as the Epley maneuver effectively treating BPPV in clinical settings. For acute vestibular syndrome patients, symptomatic treatment with medications like meclizine or benzodiazepines may provide temporary relief during acute episodes, but these should be limited to a short duration to avoid long-term dependency. Additionally, vestibular rehabilitation exercises can play a key role in recovery, particularly for patients with vestibular neuritis, where early mobilization is critical for recovery. Tailoring management to the patient's specific type of dizziness significantly enhances treatment outcomes and overall patient satisfaction.
Critical Insights on Imaging and Referral
Imaging, particularly MRI, plays a crucial role in the evaluation of dizzy patients, but it is important to recognize its limitations, especially in the early stages following an acute event. MRIs may miss up to 20% of cerebellar strokes within the first 48 hours due to delayed structural changes, underscoring the relevance of clinical examination findings. If initial imaging does not correlate with the clinical suspicion of a stroke in dizzy patients, reassessment and possible repeat imaging may be warranted. Furthermore, recognizing when to refer patients to specialists or dizziness clinics is pivotal in managing complex cases, ensuring that patients receive the best possible care tailored to their specific condition.
A simplified approach to dizziness/vertigo with tips from international expert, Dr. David Newman-Toker, Professor of Neurology, Ophthalmology and Otolaryngology at Johns Hopkins University. We learn how to differentiate stroke from other causes of dizziness/vertigo; how to approach the differential diagnosis in dizziness/vertigo; how to perform the Dix-Hallpike test, Epley maneuver, and HINTS exam; plus, who benefits from medical therapy and vestibular rehab.
Special thanks to Dr. Cyrus Askin who found our expert, wrote the questions for this episode, and acted as our cohost.
Case: A 45-year-old man presents to the emergency department because of continuous dizziness, nausea, vomiting and unsteady gait that began 18 hours earlier.
Remember Everything You Learn from Podcasts
Save insights instantly, chat with episodes, and build lasting knowledge - all powered by AI.
