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Home | Articles | Neurology | Acute Vertigo

Acute Vertigo

Last updated 28th February 2022

Structures of the Vestibular Apparatus. This work by Cenveo is licensed under a Creative Commons Attribution 3.0 United States (http://creativecommons.org/licenses/by/3.0/us/).

What is Meant by Vertigo?

  1. Vertigo means a spinning sensation or false sense of motion
  2. Causes are either peripheral (vestibular +/- cochlear division 8th cranial nerve), or central (cerebellopontine angle, brain stem or cerebellum)
  3. Vomiting frequently accompanies vertigo of any kind
  4. Peripheral causes often (but not always) accompanied by tinnitus and deafness
  5. Nystagmus is the principal sign – horizontal can be peripheral or brain stem but vertical typically mean a central lesion
  6. Central causes usually have other clinical signs eg diplopia, cranial nerve palsies, cerebellar or long tract signs.

Differential Diagnosis

  1. Patients with vertigo will usually complain of dizziness
  2. Should ask patient whether they experience a feeling of rotation OR if they are light headed as if about to faint OR simply unsteady on their feet
  3. It’s often more difficult to do this than you might think
  4. If they don’t feel sick it’s probably not vertigo

Benign Positional Paroxysmal Vertigo (BPPV)

  1. A peripheral vestibular disorder characterised by sudden onset, severe attacks of vertigo usually lasting <30 seconds and precipitated by specific head movements eg looking up or bending down, getting up, turning the head or rolling over to one side in bed.
  2. It occurs when calcium carbonate crystals that are normally embedded in gel in the utricle become dislodged and migrate into one or more of the three fluid-filled semicircular canals.  When enough of these particles accumulate in one of the canals they interfere with the normal fluid movement that these canals use to sense head motion, causing the inner ear to send false signals to the brain.
  3. Diagnosis is clinical with key diagnostic features that include episodic vertigo (repeated attacks over days, weeks or months), absence of tinnitus or hearing loss, normal neuro exam, positive Dix-Hallpike manoeuvre and normal otological exam.
  4. Treatment is Epley’s manoeuvre

Vestibular Neuritis

  1. Vestibular neuritis (aka vestibular neuronitis) occurs when an infection (usually viral) affects the vestibular branch of the 8th nerve, resulting in acute vertigo but no tinnitus or hearing loss.
  2. Vertigo can range from mild to severe and is associated with nausea and/or vomiting. If patient doesnt feel sick then it’s probably not vertigo.  Symptoms can also include unsteadiness,  imbalance and impaired concentration.
  3. Symptoms will last at least 24 hours and may go on for weeks if untreated.
  4. Early treatment with steroids has been shown to accelerate recovery

Labyrinthitis

  1. Labyrinthitis occurs when an infection affects both branches of the 8th nerve
  2. Viral infections of the inner ear are more common than bacterial.
  3. Viral labyrinthitis is typically associated with a preceding URTI.  Other viral causes include VZV, CMV, mumps, measles, rubella and HIV.
  4. Bacterial labyrinthitis is associated with acute or chronic otitis media, meningitis and cholesteatoma.
  5. Symptoms are the same as for vestibular neuritis but with tinnitus and/or hearing loss
  6. Most episodes last for hours rather than days (which distinguishes labyrinthitis from vestibular neuritis.
  7. Treatment is symptomatic with vestibular suppressants and anti-emetics

Vestibular Migraine

  1. A common cause of vertigo and the most common cause of spontaneous episodic vertigo.
  2. Migraine usually causes severe headache followed by a period of feeling completely washed out.  However many migraine patients have no headache, their predominant symptom instead being vertigo or dizziness/dysequilibrium, confusion, disorientation, dysarthria, visual distortion or altered visual clarity, or limb weakness.
  3. Management is similar to the recommended treatment of migraine headaches, and includes dietary and lifestyle modifications, and prophylactic therapies (beta blockers, calcium channel blockers and tricyclic antidepressants).

Meniere’s Disease

  1. Auditory disease characterised by episodic, sudden onset vertigo with hearing loss and roaring tinnitus and a sensation of pressure or discomfort in the affected ear.
  2. Vertigo lasts minutes to hours and may be associated with nausea and vomiting.  Hearing and tinnitus return to normal in between attacks.
  3. Risk factors for MD include age >40 years, family history, recent viral illness and autoimmune disorders
  4. Treatment is with betahistine 16-24mg tds.  Cinnarizine can be given if doesn’t tolerate betahistine.
  5. Thiazide diuretics (which reduce endolymph) are recommended for patients with recurrent attacks not controlled by betahistine or cinnarizine.
  6. Vestibular and balance rehab is recommended for patients who have problems with balance

Post-traumatic Vertigo

  1. Typically occurs as a result of blunt trauma as a result of a fall, an assault or a motor vehicle accident.  Other causes are postsurgical (middle ear surgery or cochlear implantation) and diving.
  2. Patients may complain of vertigo, dysequilibrium, tinnitus, pressure, headache and diplopia.
  3. Nearly all these patients experience BPPV long term

Cerebrovascular Causes

  1. Cerebellar stroke due to infarction or haemorrhage may present in a similar fashion to peripheral causes of vertigo with suddent intense vertigo, nausea and vomiting.  Bilateral or vertical nystagmus may suggest a central cause.  Other neuro signs include limb ataxia and impaired gait.
  2. Lateral medullary syndrome – acute vertigo with ipsilateral loss of sensation on face, contralateral loss of sensation and power in limbs, suggests lateral medullary or Wallenberg’s Syndrome (thrombosis of the posterior inferior cerebellar artery).
  3. Patients with cerebellar stroke usually cannot stand without support, even with their eyes open, whereas a patient with acute vestibular neuritis or labyrinthitis is usually able to do so.
  4. Unlike peripheral causes the head impulse test is negative (no saccadic adjustment of the eyes on sudden head twisting).
  5. CT head will show haemorrhage but is poor at showing posterior fossa infarction.  Urgent MRI should be requested in all patients with acute vertigo who have significant focal neuro suggesting posterior circulation stroke whose CT head scan is normal

Neoplastic Causes

  1. Posterior fossa tumours may present with vertigo and gait abnormality as well as other symptoms suggesting raised intracranial pressure eg headache, altered mental status, nausea and/or vomiting.
  2. Acoustic neuroma is suggested by unilateral progressive vertigo with tinnitus and hearing loss +/= involvement of cranial nerves 5,6 and 7 at the cerebellar pontine angle.
  3. Neuroimaging with CT/MRI is essential.

Dix-Hallpike Test

  1. Sit patient on bed so that when lying down their shoulders will be level with the end of the bed.
  2. Start with ear that is least expected to be the problem.  If no evidence laterality then it doesn’t matter which ear is tested first.  Using both hands turn head to 45 degrees.
  3. Ask patient to fix eyes on a point directly in front of them throughout the test.
  4. On count of three bring head back quickly over the end of the bed so that it is hanging 15-20 degrees below the horizontal.
  5. Maintain this position for 30-60 seconds observing for vertigo and nystagmus.
  6. On count of three bring patient slowly back to sitting position while maintaining head position at 45 degrees rotation, again observing for vertigo and nystagmus.
  7. Repeat with head turned 45 degrees to other side
  8. Test is negative if no nystagmus observed in either sitting or lying positions
  9. Test supports BPPV if produces vertigo and nystagmus after intial delay.
  10. Nystagmus with no initial delay suggests central cause.

Head Impulse Test

  1. This is a sensitive and specific test which detects unilateral hypofunction of the peripheral vestibular system caused mainly by labyrinthitis or vestibular neuritis
  2. To perform the test, instruct the patient to maintain fixation on the examiner’s nose, then rotate the patient’s head slowly to each side, then briskly back to midline, or from midline to each side.
  3. Normally, the vestibular-ocular reflex(VOR) is able to match the velocity of head rotation and fixation never leaves the nose.
  4. With a vestibulopathy on the side to which the head is quickly rotated, the impaired VOR causes the eyes to lag behind during the rapid head movement, fixation is lost and a rapid corrective eye movement (known as a saccade) back to the target occurs.
  5. The catch up saccade indicates peripheral vestibular hypofunction on the side towards which the head was rotated
  6. This test can be difficult to interpret in an older patients who struggles to follow your instructions

Unterberger Test

  1. This is a simple test to identify which labyrinth is affected in a patient with peripheral vertigo
  2. Patient walks on spot with arms forward at shoulder height and eyes closed
  3. Positive if rotates to one side by greater than 30 degrees in 30 seconds, indicating problem in ear on the side to which rotates
  4. The arm on the side to which they rotate will often drop.
  5. If ataxic or staggers during test then problem is in brain stem or cerebellum

Epley Manoeuvre

  1. Involves gentle but specific manipulation and rotation of patient’s head to shift the loose otoliths from the semicircular canals – refer to ENT

Management of Acute Vertigo

  1. Prochlorperazine 12.5 mg IM tds if vomiting.
  2. Prochlorperazine 5 – 10 mg tds orally if not vomiting.
  3. When acute rotation subsides reduce dose to 5 mg tds orally for further 7 days.
  4. IV fluids if vomiting.
  5. Bed rest and find position of least distress.

Dizzy Dogma

  1. Momentary – non organic, therefore reassure.
  2. Seconds to minutes – BPPV
  3. Minutes to hours – Meniere’s.
  4. Hours – labyrinthitis, vestibular migraine
  5. Days – vestibular neuronitis

Referral to ENT

  1. Refer for Epley manoeuvre
  2. Refer for follow up review at around 6/52 if acute attack vertigo ± tinnitus, hearing loss
  3. Refer urgently for acute total deafness in one ear ± vertigo

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