and Auscultation
Lying and standing blood pressure and pulse measurements (20-mm systolic blood pressure drop or 30 beats per minute heart rate rise) help identify orthostatic intolerance as a cause of dizziness. Auscultation of the heart, neck, and supraclavicular fossae for bruits may identify cardiac murmurs (aortic stenosis) or vertebral artery stenosis.
Differential Diagnosis
Often, a carefully elicited history supported by a competent examination yields a correct diagnosis with a clear management path, without requiring further investigation. Episodic positional vertigo lasting seconds, with paroxysmal positional nystagmus confirming BPV, leading to a liberatory manoeuvre, is a cause for celebration. Acute vestibular syndrome, where isolated spontaneous vertigo is accompanied by typical peripheral nystagmus and an unequivocally positive bedside head impulse confirming vestibular neuritis is another. Conversely, there will be instances where the diagnosis has to be avidly pursued. When the patient with episodic positional vertigo has a negative Hallpike test, it will be necessary to perform a second, third or fourth assessment on a symptomatic day before BPV is proven. When the patient with an acute vestibular syndrome does not fulfil all “HINTs plus” criteria (positive head impulse, peripheral nystagmus, absent skew, normal hearing), alternate causes of acute vestibular syndrome such as brainstem stroke should be considered. A diffusion-weighted MRI scan should be undertaken, and it may be necessary to commence an antiplatelet therapy even when there is no clear infarction, especially in the presence of vascular risk factors. Patients with recurrent spontaneous vertigo lasting hours may have no historic features or examination findings pointing to whether the vertigo is due to endolymphatic hydrops or VM. Here, the clinician may need to use audio-vestibular tests to assist with differential diagnosis and plan to urgently assess the patient on a symptomatic day to help them determine whether they are dealing with VM or MD. There is a need for methods of capturing the ictal nystagmus that accompanies acute spontaneous vertigo in patients’ own environments as additional means of identifying the underlying vestibular disorder.
References
1Bisdorff A, Von Brevern M, Lempert T, Newman Toker D: First consensus document of the committee for the classification of vestibular disorders of the bárány society. J Vestib Res 2009;19:1–13.
2Seemungal B, Kaski D, Lopez-Escamez JA: Early diagnosis and management of acute vertigo from vestibular migraine and Ménière’s disease. Neurol Clin 2015;33:619–628.
3Hamid MA: Ménière’s disease. Pract Neurol 2009;9:157–162.
4Jeong SH, Kim HJ, Kim JS: Vestibular neuritis. Semin Neurol 2013;33:185–194.
5Lee SH, Kim JS: Acute diagnosis and management of stroke presenting dizziness or vertigo. Neurol Clin 2015;33:687–689.
6Lee H, Ahn BH, Baloh RW: Sudden deafness with vertigo as a sole manifestation of anterior inferior cerebellar artery infarction. J Neurol Sci 2004;222:105–107.
7Brandt T, Dieterich M: Skew deviation with ocular torsion: a vestibular brainstem sign of topographic diagnostic value. Ann Neurol 1993;33:528–534.
8Strupp M, Fischer C, Hanss L, et al: The takeaway Frenzel goggles: a Fresnel-based device. Neurology 2014;83:1241–1245.
9Lechner C: Open Your Eyes! Video-Oculography Findings in Benign Positional Vertigo Masters of Philosophy [thesis]. University of Sydney, 2015.
10Lechner C, Taylor RL, Todd C, et al: Causes and characteristics of horizontal positional nystagmus. J Neurol 2014;261:1009–1017.
11von Brevern M, Zeise D, Neuhauser H, et al: Acute migrainous vertigo: clinical and oculographic findings. Brain 2005;128:365–374.
12Choi KD, Oh SY, Park SH, et al: Head-shaking nystagmus in lateral medullary infarction: patterns and possible mechanisms. Neurology 2007;68:1337–1344.
13Kattah JC, Talkad AV, Wang DZ, et al: HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculo motor examination more sensitive than early MR diffusion-weighted imaging. Stroke 2009;40:3504–3510.
14Islam N, Plant GT, Acheson JF: Saccadic lateropulsion or ipsipulsion. Acta Ophthalmol 2008;86:688–689.
15Kheradmand A, Zee DS: Cerebellum and ocular motor control. Front Neurol 2011;2:53.
16Brandt T, Dieterich M: “Vestibular falls.” J Vestib Res 1993;3:3–14.
Miriam S. Welgampola
Institute of Clinical Neurosciences, Royal Prince Alfred Hospital
Central Clinical School, University of Sydney
Sydney, NSW 2050 (Australia)
E-Mail [email protected]
Clinical Evaluation of the Dizzy Patient
Lea J, Pothier D (eds): Vestibular Disorders. Adv Otorhinolaryngol. Basel, Karger, 2019, vol 82, pp 12–31
DOI: 10.1159/000490268
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I. Pyykköa · J. Zoua, b · R. Gürkovc · S. Naganawad · T. Nakashimae–g
aHearing and Balance Research Unit, University of Tampere, Tampere, Finland; bDepartment of Otolaryngology – Head and Neck Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China; cDepartment of Otorhinolaryngology, Campus Grosshadern, University of Munich, Munich, Germany; dDepartment of Radiology, Nagoya University Graduate School of Medicine, Nagoya, eIchinomiya Medical Treatment and Habilitation Center, Ichinomiya, fDepartment of Otorhinolaryngology, National Center for Geriatrics and Gerontology, Obu, and gDepartment of Otorhinolaryngology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Abstract
Multidetector
