YOu Spin Me Right Round: A Neurologist’s Approach to Dizziness & Vertigoutahafp.org/wp-content/uploads/2017/02/You-Spin-Me-Right... · 2017-02-20 · You Spin Me Right Round: A

You Spin Me Right Round: A Neurologist’s Approach to Dizziness & Vertigo Peter Hannon, MD

Slide 1 You Spin Me Right Round

2017 CME-n-Ski

A Neurologist’s Approach to Dizziness & VertigoPeter Hannon, MD

https://www.youtube.com/watch?v=PGNiXGX2nLU

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Slide 2 Disclosures

2017 CME-n-Ski

• None• Can’t help tapping my feet to 80s glam rock…• I tweak slides!

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Slide 3 Objectives

2017 CME-n-Ski

• Review potential etiologies for ‘dizziness’

• Discuss strategies for an approach to dizziness

• Discuss management strategies for described etiologies of dizziness

• Discuss “can’t miss” presentations of dizziness

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Slide 4 Doc, I’m dizzy…

2017 CME-n-Skihttps://s-media-cache-ak0.pinimg.com/736x/bf/fb/02/bffb02630a3e91c0265e89132e28e563.jpg

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Slide 5 A neurologist’s perspective…

2017 CME-n-Skihttp://2.bp.blogspot.com/_e85U4QbYG7s/Rt2SVKdaKGI/AAAAAAAAAXQ/hmxzq1oDByU/s400/12+stereotypes+panel+02.jpg

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Slide 6 4 cases

2017 CME-n-Ski

• Jon Snow

• Dizziness off and on for 3-6 months• Worse when getting up quickly• Associated with:

• dimming/tunnel vision• sometimes ears ‘ringing’• feeling sweaty, ‘clammy’

• Has felt like he was going to faint in the past, never has

http://vignette4.wikia.nocookie.net/gameofthrones/images/5/56/Jon_Kill_the_Boy.jpg/revision/latest?cb=2015050812083

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Slide 7 4 cases

2017 CME-n-Ski

• Tormund Giantsbane

• Difficulty with balance• Worse at night or during sudden movements• Denies ‘world spinning’• Has fallen in the past

• No specific direction he can remember• Did have to go to the druid-urgent care

• Denies feeling light-headed when standing• Has been told in the past that he has ‘trouble with sugars’


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Slide 8 4 cases

2017 CME-n-Ski

• Cersei Lannister

• Woke up yesterday with acute ‘dizziness’• Can walk, but feels like she leans to left• Associated with:

• World ‘spinning’• Severe nausea• Feels she has decreased hearing on left

• Is ‘really healthy’ overall, though did have a ‘bad flu’ about a weak ago

http://vignette4.wikia.nocookie.net/gameofthrones/images/8/87/Cersei_Lannister_(S05E01).jpg/revision/latest?cb=20150420193418

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Slide 9 4 cases

2017 CME-n-Ski

• Gregor Clegane, aka ‘The Giant’

• Has felt ‘dizzy’ for years• Has had extensive workup from druids, healers and shaman• Lab work and imaging has all been (-)• Has seen a balance specialist in the past on multiple occasions• Denies ‘spinning’ or feeling light headed when standing

• Has difficulty characterizing dizzy symptoms• Does have a history of anxiety depression• Is worried this may be all due to ‘a chronic infection’• Is frustrated, angry and anxious that no diagnosis has been elicited

• “It makes me murder-y!”

http://kenh14cdn.com/cqcccccccccccc1139rCi2TGMYcqh/Image/2015/01/500px-Gregor_Clegane_Season_4-2c458.png

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Slide 10 Where to go from here?

2017 CME-n-Skihttp://media.gettyimages.com/videos/hong-kong-china-traffic-kowloon-woosung-street-with-cars-and-signs-video-id495295338?s=640x640

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Slide 11 Approach to ‘dizziness’

2017 CME-n-Ski

• Multiple potential etiologies

• Even in this day and age of advanced imaging, often not as helpful as H&P• Cause simply may not show up on imaging• Even MRI may have delayed or decreased sensitivity for certain

conditions • Patient’s don’t know the difference between dizziness, syncope and

vertigo…and shouldn’t be expected to• But can give valuable insight and sometimes incredibly novel and accurate

descriptions of their symptoms!

• ClearlyWe need a systematic approach to elicit cause of dizziness

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Slide 12 Let the patient tell you

2017 CME-n-Ski

• The symptom approach• Martin Samuels, MD

• “I might faint, I feel light-headed”

• “I feel like I’m going to fall”

• “I’m tilting, the room is spinning”

• “I just feel dizzy!”Samuels MA. The Dizzy Patient: A Clear-Headed approach. Clinical Experience. 1984; 1(3):23-40.http://www.cardiologyonline.com/images/Samuels_Martin_tn.jpg

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Slide 13 Let the patient tell you

2017 CME-n-SkiSamuels MA. The Dizzy Patient: A Clear-Headed approach. Clinical Experience. 1984; 1(3):23-40.

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Slide 14 Consider the time-course

2017 CME-n-SkiJung et al, Approach to dizziness in the emergency department, Clinical and Experimental Emergency Medicine, 2015;2(2):75-78

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Slide 15 I might faint, I feel lightheaded….

2017 CME-n-Ski

• Jon Snow

• Dizziness off and on for 3-6 months• Worse when getting up quickly• Associated with:

• dimming/tunnel vision• sometimes ears ‘ringing’• feeling sweaty, ‘clammy’

• Denies spinning sensation• Has felt like he was going to faint in the past, never has


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Slide 16 Pre-syncope, syncope

2017 CME-n-Ski

• Cardiovascular problem

• Causes include• Orthostatic hypotension

• Physiologic: autonomic, volume status• Medications

• Cardiac arrhythmias• Hypersensitive carotid sinus• Structural etiologies

• Cardiac, valvular, vascular stenosis

• Vasovagal (situational, micturation, post-prandial, etc)


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Slide 17 Pre-syncope

2017 CME-n-Ski

Post et al, Dizziness: A Diagnostic Approach, Am Fam Physician. 2010 Aug 15;82(4):361-368.https://s-media-cache-ak0.pinimg.com/236x/7f/b9/6d/7fb96dc0662dc34b3b4080b7ed5c4b3c.jpghttp://img.tfd.com/medical/Davis/Lab/th01.pnghttp://3.imimg.com/data3/DA/HY/MY-1838536/echo-cardiography-250x250.jpg

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Slide 18 Pre-syncope: Exam

2017 CME-n-Ski

• Neuro exam normal• Or abnormalities explained by other conditions

• May have orthostatics on testing

• Listen for carotid bruits, murmurs, arrhythmias

• Check cap refill, peripheral pulses

• Carotid massage (specialty settings only)

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Slide 19 Pre-syncope: Workup/management

2017 CME-n-Ski

• Based on suspected etiology• Minimize offending meds as tolerated• Neuro clinic--

• Discuss strategies for HoTN• HOB on 1-2” blocks, TED hose, increased salt intake, staying hydrated

• Consider• 30d event monitor• CTA H/N• TTE• ?EEG (often brought up by other providers if actual syncope or ‘spells’)

• Referrals as indicated• Cardiology• Autonomics• F&F Clinic

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Slide 20 I feel as if I might fall…

2017 CME-n-Ski

• Tormund Giantsbane

• Difficulty with balance• Worse at night or during sudden movements• Denies ‘world spinning’• Has fallen in the past

• No specific direction he can remember• Did have to go to the druid-urgent care

• Denies feeling light-headed when standing• Has been told in the past that he has ‘trouble with sugars’

http://vignette3.wikia.nocookie.net/gameofthrones/images/6/6f/Tormund_battle_bastards_main_infobox.jpg/revision/latest?cb=20160617001253

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Slide 21 Disequilibrium

2017 CME-n-Ski

• A balance problem

• Can be cerebellar • Chronic degeneration• Tumor• Toxic

• Or due to combined sensory deficits• Loss of or decreased proprioception, vision, hearing, etc

Samuels MA. The Dizzy Patient: A Clear-Headed approach. Clinical Experience. 1984; 1(3):23-40.

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Slide 22 Combined sensory deficits

2017 CME-n-Ski

http://www.tudorsirbu.com/wp-content/uploads/2015/03/sc_proprioception.jpghttps://image.slidesharecdn.com/dorsalcolumn-111109023215-phpapp01/95/dorsal-column-9-728.jpg?cb=1320807146http://www.osceskills.com/resources/Lower-Limb-Proprioception-2.jpg

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Slide 23 Combined sensory deficits

2017 CME-n-Ski

: Sensory ataxia

https://e65cf1d50bf8f2076281add8-yy2opup.netdna-ssl.com/wp-content/uploads/2017/01/homer-float-tank.jpghttps://oldagepeople.files.wordpress.com/2011/08/superstock_1597-113211.jpghttp://www.readersdigest.co.uk/sites/default/files/styles/header_v3/public/article-top/hearing-loss.jpg?itok=bPUGQR_R

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Slide 24 Combined sensory deficits : Exam

2017 CME-n-Ski

• Special emphasis on sensory exam• LT/PP/V

• Dedicated proprioception testing• Extremity position testing (toe)• FtN with eyes closed

• (can combine with test for drift)• Romberg

• DTRs• Often reduced in length-dependent fashion in neuropathies

https://sydney.edu.au/medicine/diabetes/foot/IMAGES/tuningfork.jpghttp://www.ophthobook.com/ophthalmology/eye-exam-tricks

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Slide 25 Combined sensory deficits : Management

2017 CME-n-Ski

• Testing• Neuropathy labs per AAN guidelines

• HbA1C/fasting glucose, B12 (SCD), SPEP• May consider advanced workup IF suggested by Hx

• genetics, heavy metals, etc

• Consider infectious causes if indicated by Hx• RPR (tabes dorsalis)

• May consider EMG/NCS

• PT with emphasis on gait and balance training• OT for home safety• Nightlights! • Ophthalmology, Audiology follow-up as indicated

http://www.neurology.org/content/72/2/185.full.htmlhttps://www.urmc.rochester.edu/libraries/courses/neuroslides/lab3b/slide120.cfmhttp://neuropathology-web.org/chapter8/chapter8Nutritional.html

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Slide 26 Cerebellar Ataxia

2017 CME-n-Ski

http://da.biostr.washington.edu/DA-ATLASES/Neuroanatomy/gifs/Gross/Topography/hempostnew.gifhttp://www.neuroradiologycases.com/2012/02/cerebellar-degeneration.html.

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Slide 27 Cerebellar Ataxia: Exam findings

2017 CME-n-Skihttp://library.med.utah.edu/neurologicexam/html/coordination_abnormal.html

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Slide 28

2017 CME-n-Ski

Cerebellar Ataxia: Exam, cont

• EOMI

• RAM

• “Shoot the gun” test

• “Mirror” test

• Fine motor movements (finger count)

• Station/Gaithttp://www.78stepshealth.us/examination-sequence/clinical-testing.htmlhttp://library.med.utah.edu/neurologicexam/html/coordination_abnormal.html

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Slide 29

2017 CME-n-Ski

Cerebellar Ataxia: Management

If history and physical suggestive of cerebellar dysfunction

• Brain imaging: MRI/CT• Remove offending drugs/ETOH• Consider genetic testing• PT with emphasis on gait and balance training• OT for home safety

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Slide 30 “I’m tilting, the room is spinning”

2017 CME-n-Ski

• Cersei Lannister

• Woke up 3 days ago with acute ‘dizziness’• Has been falling, consistently to left• Associated with:

• World ‘spinning’• Severe nausea• Feels she has decreased hearing on left

• Is ‘really healthy’ overall, though did have a ‘bad flu’ about a weak ago


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Slide 31

2017 CME-n-Ski

Vertigo: Vestibular dysfunction

http://www.slideshare.net/CsillaEgri/the-vestibular-system

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Slide 32

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Vestibular system


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Slide 33

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Vestibular system


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Slide 34

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Evaluation of vestibular disorders

• Is this peripheral or central vestibular dysfunction?

• Central or peripheral

• Central?• Nuclei/pathways

• Peripheral?• Cochlear (inner ear) • Retrocochlear (nerve)


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Slide 35

2017 CME-n-Ski

A few words about nystagmus

https://s3.amazonaws.com/classconnection/64/flashcards/261064/jpg/1-1497841BC7D1DE938D0.jpghttp://siloamspringsvet.com/filerequest/1066

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Slide 36

2017 CME-n-Ski

A few words about nystagmus

Rotary: https://www.youtube.com/watch?v=a1noptspSUADown beat: https://www.youtube.com/watch?v=ORbUVruf2Iw

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Slide 37

2017 CME-n-Ski

Central vs peripheral vestibular disorders

http://www.aafp.org/afp/2006/0115/p244.html

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Slide 38 Peripheral vertigo

2017 CME-n-Ski

• Can be combined horizontal and torsional nystagmus• Inhibited by fixation • Nystagmus does not change direction• Fades after a few days• Mild-moderate imbalance, able to walk• N/V may be severe• Hearing loss/changes commonly associated• Other (non-hearing) neuro symptoms rare• Latency following provocative maneuver—longer (up to 20

seconds)


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Slide 39 Peripheral vertigo: causes

2017 CME-n-Ski

• BBPV• Acoustic neuroma• Ménière’s disease• Cholesteatoma• Acute vestibular neuronitis• Perilymphatic fistula• Acute labrynthitis

• Of note:• Cochlear-type SNHL (Ménière’s) —speech discrimination generally

relatively preserved• Retrocochlear-type SNHL (vestibular neuroma)—disproportionate

amount of loss of speech discriminationhttp://www.aafp.org/afp/2006/0115/p244.htmlhttp://www.anaa.org.au/what-is-an-acoustic-neuroma/http://www.chicagoear.com/Medical%20Info/cholesteatoma.htmlhttps://www.webpt.com/blog/post/happy-better-hearing-and-speech-month-0

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Slide 40 Central vertigo

2017 CME-n-Ski

• Purely vertical, horizontal, or torsional nystagmus• Not inhibited by fixation• May last weeks to months• Nystagmus may change direction (direction of fast phase)• Imbalance can be severe; unable to stand still or walk• N/V—varies (may not be as severe as peripheral vertigo)• Hearing loss—rare• Associated neuro Sx (non-hearing)—common• Latency—up to 5 seconds


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Slide 41 Central vertigo: causes

2017 CME-n-Ski

• Stroke• Migraine• MS• CNS tumors• Infection/inflammation

http://www.aafp.org/afp/2006/0115/p244.htmlhttp://www.dizziness-and-balance.com/disorders/central/cerebellar/cerebellar.htmhttp://www.asnr.org/neurographics/3/2/1/4.shtmlhttp://www.neurolist.com/site/Progressive%20ataxia.htm

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Slide 42 “Every morning!”

2017 CME-n-Ski

• Tyrion Lannister

• Sudden onset of vertigo getting out of bed• Came on suddenly, but then ‘calmed down’• Always seem to occur in the morning!• Did recently have head trauma in a “brawl”

https://pbs.twimg.com/profile_images/668279339838935040/8sUE9d4C.jpg

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Slide 43 BPPV

2017 CME-n-Ski

• MCC of vertigo• Positional• Dix-Hallpike

• Head 45deg • Tilt back with neck over

end of table• Expect latency • Nystagmus

• Slow—towards lesion• Fast—away from lesion

https://www.acadianent.com/services-hearing/benign-paroxysmal-positional-vertigo-bppv-screening.htmlJung et al, Approach to dizziness in the emergency department, Clinical and Experimental Emergency Medicine, 2015;2(2):75-78

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Slide 44 “I was just eating my dinner”

2017 CME-n-Ski

• Sandor Clegane, aka ‘The Hound’

• Was eating dinner at the inn and had sudden onset ‘dizziness’ with N/V

• Unable to stand without falling

• Associated with:• World ‘spinning’• ? Facial droop (patient says that is chronic)• Denies hearing loss• Vision ‘seems off’

http://awoiaf.westeros.org/index.php/Sandor_Clegane

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Slide 45 Vertigo: stroke

2017 CME-n-Ski

• 2015, Stroke, Missed Ischemic Stroke Diagnosis in the Emergency Department by Emergency Medicine and Neurology Services

• 465 patients with stroke reviewed • 22% (55/280) missed at Academic Hospital, 26% (48/185) at CH• 33% missed within 3 hr window, additional 11% within 3-6hr window

• Symptoms independently associated with greater odds of missed stroke:• N/V (OR 4.02), dizziness (OR 1.99), positive stroke Hx (OR 2.4)

• 37% of posterior strokes initially misdiagnosed vs 16% anterior

• For missed strokes, only 8% were triaged as ‘code stroke’• 35% of missed strokes had neuro involvement!

Arch et al, Missed Ischemic Stroke Diagnosis in the Emergency Department by Emergency Medicine and Neurology Services. Stroke. 2016 Mar;47(3):668-73

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2017 CME-n-Skiwww.strokeassociation.org

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• FAST no posterior Sx!

• ROSIER• 2005, Lancet Neurology• 343 suspected stroke Pts assessed

• Sensitivity 92%• Specificity 83%• PPV 90%• NPV 88%

• FAST-AV (FAST + Ataxia & Visual Disturbance)• 2005, University Hospital, Essex UK• 35 stroke patients analyzed

• 11/35 (31%) were FAST negative• 5 of those 11 would have been FAST –AV (+)

https://dundeemedstudentnotes.files.wordpress.com/2012/03/rosier.pdfNor et al, The Recognition of Stroke in the Emergency Room (ROSIER) scale: development and validation of a stroke recognition instrument. Lancet Neurol. 2005 Nov;4(11):727-34.Huwez F et al, FAST-AV or FAST-AB tool improves the sensitivity of FAST screening for detection of posterior circulation strokes. Int J Stroke. 2013 Apr;8(3)Rudd et al, A systematic review of stroke recognition instruments in hospital and prehospital settings. Emerg Med J. 2015 Nov 16.

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Slide 48 Vertigo: stroke HINTS

2017 CME-n-Ski

• HINTS Head-Impulse-Nystagmus-Test-of-Skew

Jung et al, Approach to dizziness in the emergency department, Clinical and Experimental Emergency Medicine, 2015;2(2):75-78

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• HINTS• Stroke, 2009• 101 patients with AVS and 1 or more stroke risk factors• 100% sensitive and 96% specific

• What about rapid MRI?• Initial MRI diffusion-weighted imaging was falsely

negative in 12% (all <48 hours after symptom onset)

Kattah et al, HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009 Nov;40(11):3504-10

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Slide 50 I’m just dizzy!

2017 CME-n-Ski

• Gregor Clegane, aka ‘The Giant’

• Has felt ‘dizzy’ for years• Has had extensive workup from druids, healers and shaman• Lab work and imaging has all been (-)• Has seen a balance specialist in the past on multiple occasions• Denies ‘spinning’ or feeling light headed when standing

• Has difficulty characterizing dizzy symptoms• Does have a history of anxiety depression• Is worried this may be all due to ‘a chronic infection’• Is frustrated, angry and anxious that no diagnosis has been elicited

• “It makes me murder-y!”

http://kenh14cdn.com/cqcccccccccccc1139rCi2TGMYcqh/Image/2015/01/500px-Gregor_Clegane_Season_4-2c458.png

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Slide 51 Chronic Subjective Dizziness (CSD)

2017 CME-n-Ski

• Initially described as ‘phobic postural vertigo’

• 2nd most common Dx made in tertiary neuro-otology centers

• Sx fluctuate in severity for months to years

• Usually associated with other comorbid medical and psychiatric illnesses

• Almost always triggered by an acute neuro-otologic, medical or psychiatric illness

Staab JP, Chronic subjective dizziness. Continuum (Minneap Minn). 2012 Oct;18(5 Neuro-otology):1118-41.

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Slide 52 Chronic Subjective Dizziness (CSD)

2017 CME-n-Ski

• Tx• SSRIs, SNRIs• Vestibular rehab• CBT

Staab JP, Chronic subjective dizziness. Continuum (Minneap Minn). 2012 Oct;18(5 Neuro-otology):1118-41.

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Slide 53 Dizziness

2017 CME-n-Skihttp://winningbysharing.typepad.com/oaxaca/2006/04/the_big_picture.html

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Slide 54 Dizziness: Take home points

2017 CME-n-Ski

• Categorize potential etiology—let the patient tell you!

• Pre-syncope/syncope

• Disequilibrium• Cerebellar• Multiple sensory deficits

• Vertigo• Central• Peripheral

• Chronic subjective dizziness

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Utilize history and exam to elicit etiology

• CN• EOMI• Nystagmus?• Associated CN abnormalities?

• Motor• Weakness? Loss/gain of tone?

• DTRs• Focal findings?• Evidence of neuropathy?

• Coordination• Ataxia, dysmetria

• Sensation• Focal findings?• Evidence of neuropathy?• Evidence of loss of proprioception?

• Station• Romberg (+)?

• Gait• Wide based? Directional lean?

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Consider special testing

• Orthostatics• Dix Hallpike• Shoot the gun• Finger mirror testing• HINTS testing

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Diagnostics as indicated per suspected etiology

• EKG• TTE• Event monitor• Vascular Imaging• MRI/CT

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Refer as needed

• Cardiology• Neurology• ENT• PT/OT• Psych/SW

• Specialty clinics• Autonomics• Faint & Fall

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Slide 59 Thank you!

2017 CME-n-Ski

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Slide 60 Questions/Discussion?

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Documents

YOu Spin Me Right Round: A Neurologist’s Approach to Dizziness & Vertigoutahafp.org/wp-content/uploads/2017/02/You-Spin-Me-Right... · 2017-02-20 · You Spin Me Right Round: A