Dizziness

The outpatient approach to dizziness

1. The Outpatient Approach To Dizziness Presenter Dr Zuber Ali Quazi Senior Resident 1 st year DM Neurology

2. Dizziness Rotational sensation (Type I dizziness), Impending faint (Type II dizziness ), Dysequilibrium (Type III dizziness) and Vague lightheadness (Type IV dizziness) A Mukherjee et al; Vertigo and dizziness— A clinical approach; Nov 2003; vol 51 JAPI V ertigo in which the patient feels that either he/she or the environment is spinning . loss of consciousness . Pallor, dimness of vision, roaring in the ears, and diaphoresis, with recovery upon assuming the recumbent position loss of balance without an abnormal sensation in the head. vague lightheadedness other than vertigo , faintness or dysequilibrium

3. International Classification of Vestibular Disorders of the Bárány Society Vertigo :- Sensation of self-motion when no self-motion is occurring or the sensation of distorted self-motion during an otherwise normal head movement. Dizziness :- Sensation of disturbed or altered spatial orientation without the feeling of false motion CONTINUUM (MINNEAP MINN) Approach to the History and Evaluation of Vertigo and Dizziness 2021;27(2 , NEURO-OTOLOGY ): 306–329 .

4. NON-VERTIGO DIZZY PATIENTS Giddiness is a favourite term used by these patients. Majority of dizzy patients presenting to a doctor falls in this category Describe their symptoms in various words but Usually lack the rotatory component of movement either of self or of surroundings and do not have associated features of nausea , vomiting etc. Table showing Non Vertigo Dizziness causes

5. Subtypes of Vertigo and Dizziness Spontaneous: occurs without obvious trigger Triggered: occurs with an obvious trigger • Positional: triggered after changing head position • Head motion: occurs only during head motion • Visually induced: triggered by seeing objects in motion in the visual surround • Sound-induced: triggered by sound • Valsalva-induced: triggered by Valsalva maneuver or straining • Orthostatic: triggered by change in body position from lying or sitting to standing • Other triggered forms CONTINUUM (MINNEAP MINN) Approach to the History and Evaluation of Vertigo and Dizziness 2021;27(2 , NEURO-OTOLOGY ): 306–329 .

6. EVALUATING THE DIZZY PATIENT The history should explore four major questions that distinguish the disorders producing dizziness : 1. The type of dizziness (I to IV) 2. The abruptness of attacks or continuity of symptoms. 3. The relation or independence of dizziness to position or motion ( standing/sitting/lying; sudden change in position; walking ) 4. The age of the patient.

7. Vestibulovisual symptoms Visual symptoms resulting from vestibular dysfunction or from the interaction of the visual and vestibular systems; examples :- visual illusions that the environment is tilted. blurring of visual lag during head movements. Subtypes:- External vertigo: illusion that the visual surround is spinning or flowing Oscillopsia : the perception that the visual surround is oscillating or bouncing Visual lag: the illusion that the visual surround lags behind during head movement Visual tilt: the illusion that the visual surround is not true vertical Movement-induced blur

8. Postural symptoms Balance-related symptoms that occur when upright (seated, standing, walking); E xamples :- feeling unsteady, swaying, rocking only when upright Subtypes:- Unsteadiness: the feeling of being unstable when seated , standing, or walking Directional pulsion : unsteadiness with a feeling of veering or falling to a particular direction Balance-related near fall: a feeling of imminent or nearly falling due to vestibular symptoms, pulsion , or unsteadiness Balance-related fall: a complete fall due to vestibular symptoms, pulsion , or unsteadiness

9. SYMPTOM DESCRIPTION Spinning , whirling, rotational sensations, tilting , sinking, free-falling, or rising -- Dizziness and lightheadedness , nausea , yawning, visible pallor observed by others, diaphoresis, and a feeling as though one is about to pass out --- A multitude of sensations , including spinning, rocking, floating, motion sickness, and visually induced vertigo and dizziness-- Feeling of s pinning sensation with nausea and vomiting, often to the point they do not want to even move during attacks .-- vestibular process cardiovascular causes vestibular migraine Ménière disease

10. SYMPTOM ONSET. A cute vertigo after significant head trauma suggests a traumatic vestibulopathy . The onset of rocking or swaying dizziness without nausea after a cruise suggests mal de débarquement . Onset of dizziness after turning in bed or tilting the head can suggest BPPV. Abrupt onset of vertigo and loss of equilibrium without known provocation can suggest a vascular mechanism. Symptoms that begin after initiation of a new medication can indicate a medication is the cause.

11. SYMPTOM PERIODICITY Vestibular migraine Some have episodes of vertigo but no symptoms in between, Some have continuing susceptibility to motion sickness and visually induced vertigo but try to avoid those triggers. some have periodic spontaneous vertigo spells . Ménière disease:- E pisodic (often with some residual symptoms for a few days) Vestibular neuritis:- M onophasic course of abrupt severe symptoms with slow and gradual resolution over a week to several months. BPPV :- is characteristically episodic.

12. DURATION OF SYMPTOMS <1 minute:- BPPV Lasting minutes:- TIA affecting vestibular structures Vestibular migraine. Lasting 2 to 6 hours:- Ménière disease Vestibular migraine. Chronic symptoms:- Persistent postural perceptual dizziness. Mal de débarquement , Bilateral vestibulopathy Cerebellar degeneration.

13. TRIGGERS Dix- Hallpike manoeuvre ----BPPV Fragrances , certain visual stimulation, or excessive head motion ----Vestibular migraine P ostural changes--- Orthostatic Hypotension or Postural Tachycardia Syndrome ( POTS)

14. ASSOCIATED FEATURES Ménière disease:- Attacks can be preceded by or are a/w u/l fullness of ear and muffled hearing and louder low-pitched roaring tinnitus. TIA:- may be associated with focal hemisensory symptoms, dysarthria, diplopia, or hemiataxia Superior canal dehiscence syndrome:- may be accompanied by autophony , a heightened hearing of internal body sounds. Cerebellar Ataxia:- May be accompanied by dysarthria, gait ataxia, and ocular motor abnormalities causing blurry vision during gaze changes. Anxiety :- Loss of control, and feelings of uncertainty about when symptoms occur or whether they become severe.

15. IMPACT ON QUALITY OF LIFE Some patients may have minor dizziness, but they are very worried about it due to their own concerns with having something serious. In some of those cases, once they feel it has been adequately established to be benign, they do not want any medication but would consider other approaches. Some patients, e.g., persistent postural perceptual dizziness, may have a normal examination but view their lives as severely negatively impacted by the symptoms.

16. Eye movements Lateropulsion / Ipsipulsion of Saccades:- Lateral medullary syndrome. Saccadic dysmetria :- bidirectional o vershooting of the target and occasional undershooting--- Cerebellar Vermis and Fastigial Nucleus. Skew deviation:- more commonly– Central lesion, also seen in peripheral lesion. Skew deviation from peripheral vestibular lesions has a small amplitude and abates within days

17. Nystagmus Spontaneous downbeating nystagmus:- Central Origin & localizes to the cerebellar vermis and cervicomedullary junction . The most common conditions causing it are cerebellar ataxias , less commonly Chiari malformation or multiple sclerosis Spontaneous upbeating nystagmus:- seen in Cerebellar Ataxias, Multiple Sclerosis, Wernicke Syndrome, Autoimmune Encephalitis. When the spontaneous nystagmus is right beating and changes to left beating with gaze to the left, ----- central origin. Positional Nystagmus:- BPPV ; P osterior semicircular canal -vertical-torsional deviation Horizontal semicircular canal -a horizontal deviation with a slight torsional component

18. Gait disturbance Positive Romberg’s sign :- Bilateral Vestibulopathy or Somatosensory Dysfunction Wide based gait: - chronic communicating hydrocephalus, Ataxic neuropathy, Hypothyroidism, cerebellar dysfunction. Cautious gait :- longer stride length and longer stance time using the ipsilesional leg and an overall tendency to minimize head movements- Vestibular neuritis. Patients with Acute Vestibular Loss will veer toward the side of the affected ear. Between bouts of vertigo, in BPPV and Ménière disease and with vestibular migraine , the gait is mostly normal.

19. TiTrATE test Newman- Toker DE, Edlow JA. TiTrATE : A Novel, Evidence-Based Approach to Diagnosing Acute Dizziness and Vertigo.  Neurol Clin . 2015;33(3):577-viii .

20. Timing-and-trigger–based vestibular syndromes Timing Obligate Triggers Present No Obligate Triggers Acute; Episodic t-EVS ( eg , BPPV) s-EVS ( eg , cardiac arrhythmia) Acute; Continuous t-AVS ( eg , post gentamicin) s-AVS (eg, posterior circulation stroke) Chronic; Persistent Context-specific chronic vestibular syndrome ( eg , uncompensated unilateral vestibular loss, present only with head movement) Spontaneous chronic vestibular syndrome ( eg , chronic, persistent dizziness associated with cerebellar degeneration) t= triggered; s= spontaneous AVS= Acute vestibular syndrome EVS= Episodic vestibular syndrome

21. CONTINUUM (MINNEAP MINN) Approach to the History and Evaluation of Vertigo and Dizziness 2021;27(2 , NEURO-OTOLOGY ): 306–329 .

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23. Newman- Toker DE, Edlow JA. TiTrATE : A Novel, Evidence-Based Approach to Diagnosing Acute Dizziness and Vertigo.  Neurol Clin . 2015;33(3):577-viii . Syndrome Targeted Examination Benign Disorder Dangerous Mimic Safe to go features t-EVS Orthostatic vitals; Dix Hallpike test BPPV Posterior fossa mass No pain, auditory, neurologic symptoms, or syncope Symptoms not limited to arising and occur when tipping head forward/back or rolling in bed Asymptomatic with head stationary, symptoms reproduced by specific positional tests Therapeutic response to modified Epley maneuver ; s-EVS Head, neck, ear, and cranial nerve Vestibular migraine Menie`re disease TIA No cardiorespiratory symptoms or transient loss of consciousness No diplopia, dysarthria, dysphagia, dysphonia, dysmetria . No papilledema, Horner syndrome, cranial nerve signs. No sudden, severe, or sustained pain (especially located in the posterior neck) Strong/long past history of dizziness episodes (at least 5 spells over >2 years) Clear precipitants ( eg , stress, food, visual motion) for multiple episodes ABCD2 risk score < 3 History of migraine headache; classic visual aura or photophobia with most attacks. Meniere: history of unilateral fluctuating hearing loss or tinnitus with most attacks.

24. Syndrome Targeted Examination Benign Disorder Dangerous Mimic Safe to go features s-AVS HINTS; Ear & Hearing Examination Vestibular neuritis Stroke Maximum 1 prodromal spell <48 h before onset No excessive vomiting or gait disorder No pain, auditory, neurologic symptoms No papilledema, Horner syndrome, cranial nerve signs Stands and walks unassisted (even if unsteady or wide based, unable to perform tandem gait) No vertical ocular misalignment, No Skew deviation No deafness Unidirectional nystagmus worse in gaze toward fast phase. Healthy otic and mastoid examination No pain on palpation of the mastoid.

25. Edlow JA. The timing-and-triggers approach to the patient with acute dizziness. Emerg Med Pract . 2019 Dec;21(12 ):1-24. Epub 2019 Dec 21.

26. Edlow JA. The timing-and-triggers approach to the patient with acute dizziness. Emerg Med Pract . 2019 Dec;21(12):1-24.Epub 2019 Dec1 Characteristics of pts with t-EVS that suggest Central Paroxysmal Positional Vertigo (CPPV) vs BPPV 1. Presence of symptoms/sign NOT seen in BPPV:- Headache Diplopia Abnormal cranial nerve or cerebellar examination 2. Atypical nystagmus characteristics or symptoms during positional tests: Down beating nystagmus Spontaneous nystagmus, persistent for >90 seconds. Prominent nystagmus with mild or NO dizziness/ vertigo. 3. Poor response to therapeutic maneuvers :- Repetitive vomiting during positional maneuvers Unable to cure patients with canal specific canalith repositioning maneuver Frequent recurrent symptoms.

27. The most common diagnoses of AVS are vestibular neuritis and stroke (about 5%-10% of cases), which can be indistinguishable with history and general neurologic examination. Even MR with diffusion-weighted imaging (DWI) in the first 24 to 48 hours of an attack may be falsely negative in 6% to 21% of strokes. When smaller strokes (<1 cm in diameter) present with s-AVS, early MRI sensitivity is only approximately 50 %. Repeat delayed MRI-DWI (3–7 days after onset of symptoms )--for confirmation. Approximately 29% of patients with vertigo caused by a posterior circulation stroke reported a preceding isolated episode of vertigo that lasted for minutes. Transient isolated vertigo attacks -------- vascular imaging should be considered. Because there is potential for acute MRI results to be false negative, perfusion studies may be helpful, if posterior circulation stroke is suspected. Choi JH, Oh EH, Park MG, et al. Early MRI-negative posterior circulation stroke presenting as acute dizziness. J Neurol. 2018;265(12 ):2993-3000 . Vertigo and dizziness practical neurology

28. Risk factors for Posterior circulation stroke High Risk Factors: Gait disturbance Focal neurologic complaints suggesting cerebellar dysfunction (Diplopia, Dysarthria, Dysphagia, ataxia , Vertigo) Moderate Risk Factors Sudden onset of symptoms. Headache Low Risk or Non-predictive Factors Positional symptoms Isolated vertigo (0.7% risk of Stroke) Auditory symptoms   Kerber KA, Zahuranec DB, Brown DL, et al. Stroke risk after nonstroke emergency department dizziness presentations: a population-based cohort study. Ann Neurol. 2014;75(6):899-907.

29. In an analysis of 9472 patients from a large National Hospital Ambulatory Medical Care Survey (NHAMCS) database of ED patients, The causes of dizziness listed in the charts by the attending emergency physicians were as follows: General medical conditions (toxic, metabolic, & infectious): 49% Otologic or vestibular conditions: 33% Cardiovascular causes: 21% Respiratory conditions: 12% Neurological diseases: 7% Cerebrovascular causes: 4%

30. It is a common misconception that dizziness made worse by head motion (including positional testing) is a sign of peripheral vestibular disease, and, specifically, BPPV. Distinction between dizziness that is exacerbated by head motion and dizziness that is triggered by head motion. An AVS patient (symptomatic at baseline) examined using the Dix Hallpike test will almost invariably have increased symptoms and increased intensity nystagmus (exacerbated). These patients will feel worse with any head movement. Only if the Dix- Hallpike test induces symptoms and nystagmus from a t-EVS patient with a history of brief, recurrent spells triggered by specific head movements with no symptoms at baseline------- diagnostic of BPPV. Dix- Hallpike test should be reserved for use in patients with t-EVS. Edlow JA, Newman- Toker D. Using the Physical Examination to Diagnose Patients with Acute Dizziness and Vertigo. J Emerg Med. 2016 Apr;50(4):617-28 .

31. Findings on the HINTS examination that suggest stroke are given the acronym INFARCT (impulse normal, fast-phase alternating, and refixation on cover test ). Thus , if an s-AVS patient has any 1 of these 3 eye signs (bilaterally normal head impulses; direction-changing, gaze-evoked nystagmus; or vertical skew deviation ), stroke is likely.

32. References Bradley 8 th edition. CONTINUUM (MINNEAP MINN) Approach to the History and Evaluation of Vertigo and Dizziness 2021;27(2, NEURO-OTOLOGY): 306–329 . Newman- Toker DE, Edlow JA. TiTrATE : A Novel, Evidence-Based Approach to Diagnosing Acute Dizziness and Vertigo.  Neurol Clin . 2015;33(3):577-viii . Edlow JA. The timing-and-triggers approach to the patient with acute dizziness. Emerg Med Pract . 2019 Dec;21(12):1-24.Epub 2019. Choi JH, Oh EH, Park MG, et al. Early MRI-negative posterior circulation stroke presenting as acute dizziness. J Neurol. 2018;265(12):2993-3000 . Kerber KA, Zahuranec DB, Brown DL, et al. Stroke risk after nonstroke emergency department dizziness presentations: a population-based cohort study. Ann Neurol. 2014;75(6):899-907 Grad A, Baloh RW. Vertigo of vascular origin. Clinical and electronystagmographic features in 84 cases. Arch Neurol.1989;46(3 ):281-284. Kattah JC. Use of HINTS in the acute vestibular syndrome. an overview. Stroke Vasc Neurol. 2018;3(4):190-196 . A Mukherjee et al; Vertigo and dizziness— A clinical approach; Nov 2003; vol 51 JAPI.