An Approach to Vertigo

Summary

This video by Eric from Strong Medicine offers a comprehensive guide on diagnosing vertigo, distinguishing it from lightheadedness and disequilibrium, which are often confused with dizziness. It outlines the differences, common causes of vertigo such as BPPV and Meniere's disease, and emphasizes the importance of the Hints exam in identifying central versus peripheral causes. The video also provides an evaluation algorithm and highlights the necessity of considering neuroimaging to rule out serious conditions like stroke.

Takeaways

• 📝 Dizziness is a nonspecific term that can refer to vertigo, pre-syncope, or disequilibrium, and it's crucial to distinguish between these conditions for accurate diagnosis.
• 🎢 Vertigo is characterized by the illusion of motion while stationary, often described as a spinning sensation, and is associated with nausea due to disruptions in vestibular pathways.
• 🕊 Benign Paroxysmal Positional Vertigo (BPPV) is the most common cause of vertigo, caused by dislodged otolith crystals in the semicircular canals, and is diagnosed using the Dix-Hallpike maneuver.
• 🌀 Meniere's disease is another cause of episodic vertigo, associated with progressive hearing loss and tinnitus, and is suggested by symptoms like episodic hearing loss and tinnitus.
• 💉 Vestibular neuritis, likely due to viral inflammation, is a common peripheral cause of vertigo that can be distinguished from central causes through physical examination.
• 🏥 Central causes of vertigo, such as stroke or multiple sclerosis, are less common but require immediate attention, and may necessitate brain MRI or MRA for diagnosis.
• 🔍 The history and physical examination are primarily used to diagnose vertigo, with blood tests being rarely helpful, and imaging reserved for suspected central causes.
• 👁️ The head impulse test, nystagmus examination, and test of skew, collectively known as the HINTS exam, are critical for differentiating between central and peripheral vertigo.
• 🚑 An abnormal HINTS exam, especially in older patients with stroke risk factors or additional neurologic symptoms, should prompt immediate neuroimaging to rule out central causes like stroke.
• 📉 Audiometry is important when Meniere's disease is suspected, helping to distinguish it from other causes of vertigo based on hearing test results.
• 🔄 The diagnostic approach to vertigo involves a stepwise evaluation starting from patient history, physical examination, and specific maneuvers, followed by additional tests as needed based on the suspected cause.

Q & A

What is the main difference between vertigo, lightheadedness, and disequilibrium?

Vertigo is the illusion of motion while stationary, often described as a spinning sensation. Lightheadedness, or pre-syncope, is the sensation of transiently slowed consciousness or feeling faint, which can progress to a brief loss of consciousness. Disequilibrium is difficulty maintaining balance, usually associated with frequent falls without loss of consciousness.

What is the most common symptom associated with vertigo?

The most frequently associated symptom with vertigo is nausea.

How can benign paroxysmal positional vertigo (BPPV) be triggered?

BPPV can be triggered by changes in head position, such as moving from lying to sitting or standing, or when turning the head while supine.

What is Meniere's disease and what are its typical symptoms?

Meniere's disease is believed to be associated with an increased volume of endolymph, a fluid in the inner ear. Symptoms include discrete episodes of vertigo lasting between 20 minutes and a day, progressive hearing loss, and tinnitus.

What is the general mechanism behind lightheadedness?

The general mechanism of lightheadedness is a transient reduction of cerebral perfusion.

What is vestibular neuritis and what is its likely cause?

Vestibular neuritis is a benign self-limited disorder thought to be most likely due to viral or post-viral inflammation of one or both vestibular nerves.

How can an acoustic neuroma present symptoms of vertigo?

An acoustic neuroma, also known as a vestibular schwannoma, is a benign tumor of the vestibular nerve. As it grows slowly, unilateral hearing loss is a more common symptom than vertigo, but the central vestibular centers can adapt to the lack of unilateral vestibular inputs.

What is the purpose of the Dix-Hallpike maneuver in the evaluation of vertigo?

The Dix-Hallpike maneuver is a test specifically for BPPV. It helps to confirm the diagnosis of BPPV by inducing nystagmus with the maneuver.

What does the HINTS exam stand for and why is it important in the evaluation of vertigo?

The HINTS exam stands for Head Impulse, Nystagmus, and Test of Skew. It is important in the evaluation of vertigo because it helps to distinguish central from peripheral causes of vertigo with high predictive values.

What are some additional tests that might be indicated in the evaluation of vertigo?

Additional tests that might be indicated include audiometry for suspected Meniere's disease, and a brain MRI plus or minus MRA if a central cause cannot be ruled out from the history and exam alone.

What is the key takeaway from the video regarding the evaluation of vertigo?

The key takeaway is that the diagnosis of vertigo is predominantly based on history and physical exam, with the HINTS exam being an important component. An abnormal HINTS exam should warrant an MRI plus or minus an MRA to look for central causes such as a posterior circulation stroke or multiple sclerosis.

Outlines

00:00

🌀 Understanding Vertigo and Its Distinctions

This paragraph clarifies the difference between vertigo, lightheadedness, and disequilibrium, which are often collectively referred to as dizziness. Vertigo is characterized by the illusion of motion while stationary, often described as a spinning sensation, and is associated with nausea. It can be caused by disruptions in the vestibular pathways. Lightheadedness, or pre-syncope, involves a sensation of faintness and can lead to brief loss of consciousness. Disequilibrium is the difficulty in maintaining balance, often without loss of consciousness. The paragraph emphasizes the importance of distinguishing these conditions for accurate diagnosis.

05:00

👂 Causes of Vertigo: Peripheral and Central Ideologies

The second paragraph delves into the causes of vertigo, categorizing them into peripheral and central ideologies. Peripheral causes include benign paroxysmal positional vertigo (BPPV), Meniere's disease, perilymphatic fistula, and Cogan syndrome, which involve the inner ear or vestibular nerves. Central causes, less common, can be vascular or non-vascular and include conditions like transient ischemic attacks, migraines, and multiple sclerosis. The paragraph highlights the importance of identifying the cause to determine the appropriate diagnostic and treatment approach.

10:02

🔍 Diagnostic Framework for Vertigo

This paragraph discusses the diagnostic framework for vertigo, emphasizing the differentiation between peripheral and central causes. It describes the history-taking process, focusing on the nature of the sensory disturbance, the time course, and triggers of vertigo. The paragraph also mentions associated symptoms, such as hearing loss and tinnitus, which can point towards specific conditions like Meniere's disease. The diagnostic process relies heavily on the patient's history and physical examination, with the Dix-Hallpike maneuver being a key test for BPPV.

15:02

📝 The HINTS Exam and Dix-Hallpike Maneuver

The fourth paragraph introduces the HINTS exam (Head Impulse, Nystagmus, and Test of Skew) as a critical component in evaluating vertigo, with high predictive values for distinguishing central from peripheral causes. It details the steps and significance of the head impulse test, nystagmus test, and skew test. The Dix-Hallpike maneuver is also described for diagnosing BPPV, with the presence of nystagmus indicating a positive test. The paragraph advises on the appropriate use of these tests based on the patient's symptoms and history.

20:02

🛑 Algorithm for Evaluating Vertigo

The final paragraph presents an algorithm for evaluating vertigo, starting with discerning between dizziness, lightheadedness, and disequilibrium. It outlines the steps for further workup based on the patient's clinical presentation, such as the Dix-Hallpike maneuver for BPPV or audiometry for Meniere's disease. The paragraph also discusses the importance of neuroimaging in cases of suspected central vertigo, especially in patients with risk factors for stroke. It concludes with the emphasis on the accuracy of the HINTS exam and the need for caution to avoid missing serious conditions like posterior circulation strokes.

Keywords

💡Vertigo

Vertigo is defined as the illusion of motion while a person is stationary, often described as a spinning sensation. It is the main focus of the video and is distinguished from other types of dizziness. The script explains that vertigo can last from seconds to weeks and is associated with nausea, resulting from disruptions in the vestibular pathways, which could be in the inner ear, along the cranial nerve, or in the brain.

💡Dizziness

Dizziness is a nonspecific term often used by patients to describe various sensations, including vertigo. The video emphasizes the importance of distinguishing dizziness from vertigo and other conditions. In the script, Eric clarifies that English-speaking patients rarely use the word 'vertigo,' instead opting for 'dizziness,' which necessitates further inquiry to pinpoint the exact issue.

💡Pre-syncope

Pre-syncope refers to the sensation of transiently slowed consciousness or feeling faint, which can progress to a brief loss of consciousness known as syncope. In the video, pre-syncope is one of the three categories of dizziness discussed, and it is differentiated from vertigo by its association with a feeling of warmth, visual changes, and a transient reduction of cerebral perfusion.

💡Disequilibrium

Disequilibrium is described as difficulty maintaining balance, which can be persistent or episodic and is often associated with frequent falls without loss of consciousness. The script explains that disequilibrium is usually due to sensory deficits in multiple modalities and is one of the three categories of dizziness that a patient might be referring to when they use the term 'lightheadedness.'

💡Benign Paroxysmal Positional Vertigo (BPPV)

BPPV is identified as the most common cause of vertigo and is characterized by episodes of brief vertigo triggered by changes in head position. The script describes how in BPPV, the displacement of otoliths (ear crystals) within the semicircular canals leads to excessive activation of the sensory cells, causing vertigo that lasts for seconds to minutes.

💡Meniere's Disease

Meniere's Disease is associated with an increased volume of endolymph, a fluid responsible for transmitting sound waves and detecting acceleration. The video script explains that Meniere's disease is characterized by episodes of vertigo, progressive hearing loss, and tinnitus, and it is suggested by symptoms such as episodic hearing loss or tinnitus.

💡Vestibular Neuronitis

Vestibular Neuronitis is a benign, self-limited disorder thought to be caused by viral or post-viral inflammation of the vestibular nerve. The script mentions that this condition can present with continuous vertigo and is part of the differential diagnosis when considering peripheral causes of vertigo.

💡Acoustic Neuroma

Acoustic Neuroma, also known as a vestibular schwannoma, is a benign tumor of the vestibular nerve. The video script explains that due to the slow growth of the tumor, unilateral hearing loss is a more common symptom than vertigo, but it can be associated with vertigo and is sometimes classified as a central cause of vertigo.

💡Central Causes

Central causes of vertigo are those that originate within the brain, such as a stroke or transient ischemic attack affecting the posterior circulation. The script differentiates central causes from peripheral ones and emphasizes the importance of neuroimaging for central causes to rule out serious conditions like stroke or multiple sclerosis.

💡HINTS Exam

The HINTS exam is a specific combination of tests used to distinguish between central and peripheral causes of vertigo. It stands for Head Impulse, Nystagmus, and Test of Skew. The script highlights the HINTS exam as a crucial part of the evaluation process for vertigo, with abnormal results potentially indicating a central cause that may require further investigation with MRI or MRA.

💡Dix-Hallpike Maneuver

The Dix-Hallpike Maneuver is a specific test for BPPV that involves positioning the patient's head and observing for nystagmus, which indicates the presence of BPPV. The script describes the procedure and its significance in confirming BPPV, particularly in patients with brief recurrent episodes of vertigo triggered by head movement.

Highlights

Vertigo is distinguished from dizziness and pre-syncope by the illusion of motion while stationary.

Dizziness is a nonspecific term that can refer to vertigo, pre-syncope, or disequilibrium.

Vertigo can be caused by disruptions in the vestibular pathways in the inner ear, cranial nerve, brain stem, or cerebellum.

Lightheadedness, or pre-syncope, is a transient reduction in cerebral perfusion causing a sensation of faintness.

Disequilibrium involves difficulty maintaining balance and is associated with frequent falls without loss of consciousness.

Benign Paroxysmal Positional Vertigo (BPPV) is a common peripheral cause of vertigo, caused by dislodged otolith crystals.

Meniere's disease is associated with episodes of vertigo, progressive hearing loss, and tinnitus.

A perilymphatic fistula can cause episodic vertigo triggered by changes in middle ear pressure.

Cogan syndrome is a rare autoimmune disease presenting with vertigo, hearing loss, and interstitial keratitis.

Vestibular neuritis is likely due to viral inflammation of the vestibular nerve.

Acoustic neuroma is a benign tumor that can cause unilateral hearing loss and vertigo.

Ramsey Hunt syndrome presents with unilateral facial paralysis, ear pain, and vertigo due to shingles affecting the ear.

Vestibular paroxysmia is a poorly understood condition causing brief, frequent attacks of vertigo.

Central causes of vertigo include vascular issues such as transient ischemic attacks or strokes.

Vestibular migraines and multiple sclerosis are nonvascular central causes of vertigo.

The Dix-Hallpike maneuver is a specific test for BPPV, confirming the diagnosis if nystagmus is induced.

The HINTS exam is crucial for distinguishing central from peripheral causes of vertigo.

An abnormal HINTS exam should prompt an MRI to rule out central causes such as stroke or multiple sclerosis.

Vertigo diagnosis is primarily based on history and physical exam, with imaging reserved for unclear cases or central suspicions.

The most common cause of vertigo is BPPV, which can be diagnosed and treated without extensive testing.

Transcripts

hello it's Eric from strong medicine and

today I'm discussing and approached the

Vertigo the first step is to confirm

that what a patient is describing to you

is in fact vertigo English speaking

patients rarely use the actual word

vertigo and instead will use the word

dizziness

unfortunately dizziness is nonspecific a

patient reporting this symptom might

mean vertigo or they might mean

something called pre syncope or

something sometimes called

disequilibrium let's discuss the

difference between those three I'll

start with a primary symptom of interest

for this video vertigo vertigo is the

illusion of motion while a person is

stationary most but not all patients

describe a spinning sensation if you've

ever played the game dizzy bat the

sensation that generates is vertigo

vertigo can last as briefly as a few

seconds or it can persist for weeks the

most frequently associated symptom is

nausea and the general mechanism by

which vertigo occurs is a disruption of

vestibular pathways which can happen in

the inner ear along the course of

cranial nerve eight within the best

tubular nuclei in the brain stem or

within the cerebellum

the next symptom that is frequently

referred to by patients as dizziness is

lightheadedness also known as pre

syncope this is the sensation of

transiently slowed consciousness or

feeling faint it can progress to a brief

loss of consciousness known as syncope

when lightheadedness occurs it is almost

always brief lasting seconds to no more

than a few minutes it can be associated

with a feeling of warmth throughout the

entire body and visual changes such as

blurring or graying out of the vision in

both eyes the general mechanism of

lightheadedness is a transient reduction

of cerebral perfusion

last and least understood is this

equilibrium this is difficulty

maintaining balance it can last a few

seconds or persist for weeks it's

usually associated with frequent Falls

without a loss of consciousness which

would otherwise suggest syncope affected

patients may become fearful of walking

the general mechanism is usually sensory

deficits in multiple modalities

while it's not always as unambiguous as

this chart might suggest a clinician can

usually place a patient's dizziness into

one of these three categories

now focusing just on vertigo the

diagnostic framework is best divided

into peripheral versus central

ideologies as a general rule the

peripheral ideologies are relatively

common compared to the central ones

starting with the peripheral causes

causes within the labyrinth include

benign paroxysmal positional vertigo

usually abbreviated BPPV in BPPV

the crystals known as odorless become

dislodged and flow freely in one of

these semicircular canals partially

responsible for balance

when these crystals move within the

canals in response to changes in

position they lead to excessive

activation of the canals sensory cells

so change in position which should only

be a transient sensation during the

actual movement persists for seconds to

as long as a few minutes BPPV

classically causes episodes of brief

vertigo triggered by moving from a lying

to sitting position or standing position

or when turning one's head while supine

a less common cause of episodic vertigo

due to a problem in the inner ear is

Meniere's disease this is believed to be

caused by or at least is associated with

an increased volume of a fluid called

endolymph which is responsible for

transmitting sound waves to receptor

cells in the cochlea and for detecting

angular acceleration within the

semicircular canals symptoms of nares

disease include discrete episodes of

vertigo lasting between 20 minutes and a

day associated with progressive hearing

loss and with ringing in the ears which

can either be a Poisson ik or can be

constant

a peri lymphatic fistula is a tear in

the membrane that separates the inner

and mental ear a rare complication of

head trauma or Barrow trauma which

causes episodic vertigo and our hearing

loss that's triggered by anything

associated with abrupt changes in

pressure within the middle ear

this can include sneezing coughing

straining or even loud noises

and last in this category is the rare

autoimmune disease Kogan syndrome which

presents with a combination of veneers

like attacks of transient vertigo and

hearing loss along with interstitial

keratitis and sometimes various forms of

systemic vasculitis

- the main nerves that are involved in

vestibular sensory function they include

cranial nerve eight also known as the

vestibular cochlear nerve which has two

branches one of which is the vestibular

nerve which receives signals from the

vestibular hair cells of the inner ear

that are directly responsible for

sensing position and movement the most

common etiology in this category is

called vestibular neuritis this is a

benign self-limited disorder thought to

be most likely due to viral or post

viral inflammation of one or both nerves

but a viral mechanism has not been

definitively established some clinicians

use the term vestibular neuritis

interchangeably with the term

labyrinthitis while others reserved the

latter term for only those patients who

also experience temporary hearing

abnormalities along with a vertigo

an acoustic neuroma also known as a

vestibular schwannoma is a benign

Schwann cell derived tumor of the

vestibular nerve as a consequence of the

slow growth of the tumor unilateral

hearing loss is a more common symptom

than vertigo since central vestibular

centers can gradually adapt to the lack

of unilateral vestibular inputs

sometimes acoustic neuromas are

classified as an etiology of central

vertigo presumably because their

presentation is more similar to central

ideologies but as it affects a part of

the peripheral nervous system to me it

feels more appropriately categorized

here

Ramsey hunt syndrome also known as

herpes zoster otakus is essentially

shingles affecting the ear manifesting

as unilateral facial paralysis ear pain

vesicles within the auditory canal and

on the auricle hearing loss and of

course vertigo the final peripheral

causes of vertigo I mentioned is called

vestibular Parkes is MIA which is a rare

poorly understood chronic condition

manifesting as very brief attacks of

vertigo occurring several times a day

sometimes with auditory symptoms during

attacks moving to the less common

central causes of vertigo they can be

separated into vascular versus non

vascular ideologies

among vascular causes the most notable

is a transient ischemic attack or stroke

of the posterior circulation to specific

entities here include lateral medullary

syndrome also known as Wallenberg

syndrome and infarct or hemorrhage of

the cerebellum both of these would

almost always be associated with

significant other neurological deficits

among nonvascular central causes are

migraines which are called vestibular

migraines

when vertigo is a prominent symptom and

multiple sclerosis the most common cause

of vertigo is BPPV

and those conditions which specifically

cause episodic vertigo include BPPV

Meniere's disease prairie lymphatic

fistula Kogan syndrome vestibular park's

is MIA and vestibular migraines

vertigo usually requires an asymmetry

between right and left particular inputs

and processing so any condition or

exposure that results in symmetric

dysfunction such as aminoglycoside

toxicity or alcohol intoxication tends

to cause vestibular dysfunction such as

impaired balance but without the

specific symptom of vertigo

one nice thing about the diagnostic

workup for vertigo is that even more so

than with the other symptoms I've

discussed in this video series the

diagnosis can usually be made from

symptoms and exam alone starting with

the history the first step is to have

the patient describe the nature of the

sensory disturbance that they are

experiencing that is you want to confirm

that the patient is reporting vertigo

and not lightheadedness disequilibrium

or other neurologic symptoms

next consider the time course how long

has it been present and is it episodic

or continuous is there a specific

trigger for the Vertigo most commonly a

change in position realize that all

vertigo worsens with head movement

it's only diagnostically helpful if the

vertigo is absent at rest and is

triggered by movement which specifically

suggests BPPV other triggers to ask

about include onset after head trauma as

well as triggering by coughing weight

lifting or straining with bowel

movements of which suggests a peri

lymphatic fistula there are a number of

associated symptoms to ask about

concurrent hearing loss and tinnitus or

ringing in the ears suggests Meniere's

disease headache and photophobia suggest

migraines concurrent ocular symptoms

beyond photophobia suggest Kogan

syndrome other concurrent or prior

neurologic symptoms suggest multiple

sclerosis or a posterior circulation

stroke if the patient has a deficit

imbalance that is more prominent than

vertigo it suggests bilateral and

symmetric vestibular damage which is

classic for immuno glucoside toxicity

but can also be seen with Meniere's

disease there are several relatively

unique symptoms that can be experienced

by patients presenting with vertigo the

first is called a tilt illusion which is

the sensation that everything in the

world is tilted with respect to gravity

drop attacks are sudden losses of

postural tone without a loss of

consciousness an ocelot Zea is a

sensation of to-and-fro movements of the

environment which may be either sudden

and jerky or smooth and regular when

smooth it's associated with a physical

finding called pendular nystagmus this

symptom is typically more prominent when

the patient is walking and the head is

in motion

questions about past medical history

should focus on atherosclerosis factors

and also ask about past migraines the

focused exam for a patient presenting

with vertigo should include an ear exam

and a thorough neuro exam there is a

specific combination of relevant exam

findings that have been bundled together

as the Hintz exam h ints which stands

for head impulse nystagmus and tests of

skew because the hints exam has been

reported to have very high positive and

negative predictive values for

distinguishing central from peripheral

ideologies it is a particularly

important part of the vertigo evaluation

for the head impulse test ask the

patient to look straight ahead at your

nose and keep their gaze on it while you

passively turn their head to the side

the most important phase of the movement

should be relatively quick but to make

sure you don't injure the patient a good

technique is to slowly turn the head

about 20 degrees to one side and then

quickly return it to the midline

it's also important to mix up the speeds

and direction of the movements a little

to prevent the patient from

unconsciously anticipating the movement

a normal response is for the patient's

gaze to remain on target while an

abnormal response is for the pierce

person's gaze to initially move followed

by a rapid corrective eye movement back

to the target this should be repeated in

both directions

in the case of vertigo in abnormal test

is actually reassuring since it suggests

a probable peripheral cause of vertigo

whereas a bilaterally normal response is

more consistent with a central cause

to test for nystagmus ask the patient to

look straight ahead and look for any

movements of either eye then ask the

patient to look to the extreme in one

direction and hold for a few moments and

then repeat in the other direction a

reassuring finding is either no

nystagmus at all or only unidirectional

horizontal nystagmus unidirectional

does not mean unilateral but rather that

the fast component of nystagmus is

always in the same horizontal direction

any other type of nystagmus

for example bi-directional nystagmus is

strongly suggestive of a central

etiology

you

last is the test of skew for this ask

the patient to look straight ahead at

your nose and then cover one eye for a

few seconds and then rapidly move to

cover the other eye instead and go back

and forth and look to see if there's any

movement of the uncovered eye adjustment

of the eye as it is uncovered implies a

vertical misalignment of the two eyes

and is considered a positive test

to summarize the hints exam indicates a

likely central ideology if any of the

following are present the patient has a

normal head impulse test bi-directional

or other unusual form of nystagmus or an

abnormal test of skew

the last part of a focused physical exam

for vertigo is the Dix Hal Pike maneuver

which is specifically a test for BPPV

for this the patient needs to be sitting

lengthwise on an exam table in which the

examiner is able to stand at the head

then with the patient's arms folded as

relaxed as possible and head turned 45

degrees towards the examiner the

examiner helps the patient to smoothly

but quickly lower the head straight back

and slightly over the edge of the table

the II vocation of nystagmus with this

maneuver is considered to be a positive

test and is indicative of BPPV it should

be repeated on both sides as a general

rule the hints exam is most

appropriately performed on a patient

with hours or days of continuous vertigo

whereas the Dix Hal pike is most

appropriately performed on a patient

with brief recurrence episodes of

vertigo it would be unusual for both the

hints and the Dix Hal pike to be

indicated in the same patient most cases

of vertigo can be successfully diagnosed

from the history and exam alone and new

team blood tests are rarely if ever

helpful however there are a couple of

additional tests occasionally indicated

specifically audiometry or a formal

hearing assessment if Meniere's disease

is suspected and a brain MRI plus or

minus an MRA if a central cause cannot

be ruled out from the history and exam

alone let's now look at an overall

algorithm for evaluating vertigo that

puts all this together

first we start with a patient reporting

dizziness and we must discern between

the three possible syndromes is it pre

syncope in which the patient clarifies

dizziness by describing a feeling of

faintness or like they're going to pass

out the symptom of pre syncope may be

triggered by upright posture certain

situations like urination a coughing fit

or emotional shock or it can be

spontaneous and it can be associated

with loss of consciousness

or is the patient describing

disequilibrium which the patient feels

unable to stay balanced when standing or

walking symptoms are worse with walking

and it's associated with frequent Falls

but without faintness or loss of

consciousness or is the patient's

dizziness vertigo in which the patient

feels like the room is spinning or that

they themselves are in motion vertigo is

worse with head movement and is often

associated with nausea

focusing just on the further workup of

vertigo there are four common clinical

presentations the patient could have

recurrent episodes lasting seconds to a

few minutes which are not only worsened

by movement but also triggered by

movement this is the typical

presentation for BP Bibi in which case

the next step is the Dix Hal Pike

maneuver an abnormal Dix Hal Pike

combined with the classic presentation

is sufficient to confirm BPPV however

this manoeuvre only tests for odourless

in the posterior canals which is the

most common but if there are free

odourless in the anterior or horizontal

canals the manoeuvre may be normal there

are some additional tests for these

uncommon forms of BP V V that are beyond

the scope of this particular video

contrast to the extremely brief episodes

of vertigo and BPPV

the recurrent episodes can last many

minutes two hours in this case the

patient probably has vestibular

migraines or Meniere's disease to

distinguish between them

check audiometry if the patient has

either episodic symptomatic hearing loss

episodic tinnitus or has low frequency

hearing loss as picked up on audiometry

which could be subclinical or

asymptomatic the patient probably has

maneras disease on the other hand if the

patient has neither auditory symptoms

nor abnormalities on audiometry they

likely have vestibular migraines if the

patient's vertigo has been a continuous

single episode and they have an abnormal

hints exam they probably have a central

ideology in which case a brain MRI plus

or minus MRA is indicated the urgency of

neuroimaging is dependent upon the

acuity of symptom onset if a diagnosis

is made you should further work it up as

indicated if the mr is unremarkable you

should consider rare causes or

potentially a false positive hence exam

in a patient with vestibular neuritis

and last if the patient's presentation

has been a single continuous episode

lasting days or less with or without an

Associated viral syndrome they probably

have vestibular neuritis for most

patients the appropriate next step is

symptomatic management and reassessment

in one to two weeks if symptoms resolve

no further workup is indicated unless

the vertigo recurs if the symptoms

persist then neuroimaging is usually

warranted now there's one big caveat to

this algorithm while the hints exam is

believed to be very accurate at

distinguishing central versus peripheral

causes of vertigo it's not perfect and

is examiner dependent this combined with

the fact that you really don't want to

miss a posterior circulation stroke

means that if you are considering

vestibular neuritis as the most likely

diagnosis but your patient is older has

stroke risk factors and certainly if

there are other neuro science and

symptoms present consider neuro imaging

without first waiting one to two weeks

the key takeaway points of this video

it's important to distinguish vertigo

from lightheadedness and disequilibrium

all three of which may be referred to as

dizziness by the patient

the most common etiology of vertigo is

benign paroxysmal positional vertigo a

diagnosis of which can usually be

confirmed by the Dix Hal pike manoeuvre

the diagnosis of a patient with vertigo

is predominantly based on history and

physical exam and last for hints exam

which stands for head impulse nystagmus

and test of skew is an important

component of the evaluation of vertigo

in abnormal hints exam should warrant an

MRI

plus or minus an MRA to look for central

ideologies such as a posterior

circulation stroke or multiple sclerosis

you