Assessment of Patients with Dizziness (+/- Falls

)
Dr Irene Hubard Kettering General Hospital

Unexplained Dizziness / Loss of Balance / Syncope or PreSyncope 1. True Vertigo 2. Generally off balance 3. Lightheaded / Pre-Syncopal /
Syncopal 4. Psychosomatic 5. (Falls for some other reason)

Unexplained Dizziness / Loss of Balance / Syncope or PreSyncope 1. True Vertigo 2. Generally off balance 3. Lightheaded / Pre-Syncopal /
Syncopal 4. Psychosomatic 5. (Falls for some other reason)

1.True Vertigo
• Vertigo is an illusion of rotatory

motion caused by asymmetry of neural activity between the left and right vestibular nuclei. • Exacerbated by head movement • Vertigo is always temporary.

1.True Vertigo
• VESTIBULAR LESIONS • BPPV • Vestibular neuronitis • Menieres Disease • Vestibular Migraine • CEREBELLAR LESIONS • E.g. Stroke

Benign Paroxysmal Positional Vertigo (BPPV)
• Most common cause of vertigo • Telephone diagnosis – history • Repeated bouts over time – provoked
by rolling over in bed or looking up to hang washing or down • No abnormalities on examination • Positive Hallpikes test

Left posterior semicircular canal BPPV.

Epley Manouvre

Recurrent spontaneous vertigo: is it Menière’s disease or migraine?
• The patient with repeated attacks of
spontaneous vertigo each lasting an hour or more has either Menière’s disease or migraine. • Menieres Disease – classically vertigo, vomiting, low freq hearing loss, ear fullness • But hearing loss only mild and transient initially and may not be noticed • Vestibular migraine – Vertigo and vomiting may or may not be associated with headache

The patient with a first attack of acute spontaneous vertigo
• Acute vestibular neuritis • Cerebellar infarction
– 1. In the clinical context of a first ever attack of acute spontaneous vertigo, if the head impulse test is positive then the patient has acute vestibular neuritis – 2. With a cerebellar infarct the nystagmus might be bilateral, might be vertical, and will not be well suppressed by visual fixation – that is, it will be obvious – 3. A patient with a cerebellar infarct usually cannot stand without support even with the eyes open, whereas the patient with acute vestibular neuritis usually can

• Late complications of vestibular neuritis

– BPPV, imbalance due to inadequate vestibular function

The head impulse test

Unexplained Dizziness / Loss of Balance / Syncope or PreSyncope 1. True Vertigo 2. Generally off balance 3. Lightheaded / Pre-Syncopal /
Syncopal 4. Psychosomatic 5. (Falls for some other reason)

2. Generally off balance
• Bilateral vestibulopathy • Hydrocephalus • Posterior fossa lesions • Progressive supranuclear palsy • Cerebellar ataxia • Orthostatic tremor • Spinal cord disease • Sensory neuropathy

Vestibular disorders
• Unterbergers test • Cawthorn Cooksey Exercises

• Vertibro-basilar ischaemia – usually other

Diagnoses that are likely to be wrong in a patient with isolated vertigo

brainstem signs • Otitis media – unless suppurative • Hearing symptoms, tinnitus and deafness, if unilateral and occurring at the same time as the vertigo attacks, suggest an aural rather than a brainstem problem. By contrast, sudden, temporary bilateral hearing loss does suggest brainstem ischaemia.

Unexplained Dizziness / Loss of Balance / Syncope or PreSyncope 1. True Vertigo 2. Generally off balance 3. Lightheaded / Pre-Syncopal /
Syncopal 4. Psychosomatic 5. (Falls for some other reason)

Unexplained Syncope, Falls, Dizziness
True Syncope Falls Pre-syncopal Dizziness
True vertigo
Lightheadedness

History, examination, ECG indicates: •Vasovagal syncope •Orthostatic hypotension •Drug-induced syncope •Arrythmia •Situational syncope •Major psychopathology

History, examination, radiology suggests: •BPPV

Hx & Exam: •Parkinsons

•Vestibular/cerebellar/ •Cerebellar signs ENT pathology •Periph neurop. •CVA •Other CNS signs

3. Lightheaded / Pre-Syncopal / Syncopal
• Acute M.I. / ischaemia • Neurally mediated syndromes •
- Vasovagal syncope - Carotid sinus syndrome Orthostatic hypotension - Autonomic failure- Drugs/ alcohol- Volume depletion (e.g. Haemorrhage, diarrhoea, Addisons) Cardiac arrhythmia -Bradycardia/ tachycardia Structural cardiac disease -Aortic Stenosis Pulmonary Embolism

• • •

Syncope: Etiology
NeurallyMediated
1 • Vasovagal • Carotid Sinus • Situational
Cough Postmicturition

Orthostatic

Cardiac Arrhythmia
3 • Brady
Sick sinus AV block

Structural CardioPulmonary
4 • Aortic Stenosis • HOCM • Pulmonary Hypertension

NonCardiovascular
5 • Psychogenic • Metabolic e.g. hyperventilation • Neurological

2 • Drug Induced • ANS Failure
Primary Secondary

• Tachy VT*
SVT

• Long QT Syndrome

24%

11%

14% Unknown Cause = 34%

4%

12%

DG Benditt, UM Cardiac Arrhythmia Center

CARDIOVASCULAR CAUSES OF SYNCOPE • Neurally mediated syndromes

• •

Vasovagal syncope (VVS) Carotid sinus syndrome (CSS) Orthostatic hypotension (OH) Postprandial hypotension Situational syncopes (cough, micturition, etc) Cardiac abnormalities Arrythmias Structural (aortic stenosis, HOCM) Low output states (pericardial effusion, CCF) Hypovolaemic states Haemorrhage, GI loss (D & V), renal loss (diuretics, Addison disease, diabetes mellitus/insipidus, etc) Miscellaneous Pulmonary embolism TIA

NEURALLY MEDIATED SYNDROMES - SOME DEFINITIONS
• Vasovagal Syncope • Carotid sinus syndrome • Orthostatic Hypotension

Vasovagal Syncope (Neurocardiogenic syncope)
• Often a precipitating event or prolonged
head up tilt resulting in hypotension +/or bradycardia with reproduction of presenting symptoms

Carotid Sinus Hypersensitivity
• >3 seconds of asystole (cardioinhibitory)
or a 50mmHg fall in systolic BP in the absence of cardioinhibition (vasodepressor) or both (mixed) during CSM

Orthostatic Hypotension
• 20mmHg fall in systolic or 10 mmHg fall in
diastolic BP within 3 minutes of standing or head up tilt.

Aetiology of Orthostatic Hypotension
• CVS - Low cardiac output states
(AS,HOCM), Hypovolaemia • Neurogenic failure Primary – Shy-Drager, Parkinsons, MSA Secondary – Diabetes, alcohol, amyloid • Endocrine – Addisons, Phaeochromocytoma • Drugs – CVS, diuretics, antihypertensives • Prolonged bed-rest • Idiopathic

Head-up Tilt Test (HUT)
• Used to look for neurally mediated
reflex syncopal syndromes i.e:
– Vasovagal (neurocardiogenic) syncope – Carotid Sinus Syndrome

Head-up Tilt Test (HUT)
• Unmasks VVS
susceptibility • Reproduces symptoms • Patient learns VVS warning symptoms • Physician is better able to give prognostic / treatment advice

Head-up tilt table testing in the diagnosis of vasovagal syncope, carotid sinus hypersensitivity, and related disorders.

• Vasovagal syncope – Often precipitated by

event or prolonged head up tilt causing hypotension +/- bradycardia with reproduction of presenting symptoms. asystole (cardioinhibitory) or a 50mmHg fall in systolic BP in the absence of cardioinhibition (vasodepressor) or both (mixed) during CSM.

• Carotid sinus hypersensitivity - >3seconds of

• Orthostatic hypotension – 20mmHg fall in

systolic or 10mmHg fall in diastolic BP within 3 minutes of standing or HUT.

Unexplained Dizziness / Loss of Balance / Syncope or PreSyncope 1. True Vertigo 2. Lightheaded / Pre-Syncopal /
3. 4. 5.
Syncopal Generally off balance Psychosomatic (Falls for some other reason)

4. Psychosomatic
• Anxiety Disorder / Depression • Hyperventilation

Hyperventilation
• Nijmegen Score • Arterial Blood Gases

Hyperventilation Questionnaire Nijmegen Score
• 16 Questions on symptoms such as
SOB, tingling, dizziness, palpitations, anxiety, chest tightness etc • Score 0 – 4 for never, rarely, sometimes, often or very often happens • Score >23 is significant (max 64)

What I actually do with dizzy patients in clinic
• Full history • Examination • CVS exam with Lying/Standing BP and ECG • 24hr BP / 24hr ECG / ECHO (aortic
stenosis) • CNS exam including cerebellar signs/foot sensation • Gait • Hallpike Test • Unterbergers Test • Rombergs
– True Vertigo/Impaired Balance/Lightheaded

Conclusions and Take Home Message
• Decide whether patient has
– – – – true rotational vertigo is just generally off balace or describing lightheadedness (occasionally psychogenic component)

In a patient with repeated attacks of vertigo
• Do the positional test and if positive
for BPPV go on to a particle repositioning manoeuvre • Order an audiogram and a caloric test and if they are normal think of migraine rather than Menière’s disease in a patient with recurrent vertigo • Forget about vertebro-basilar transient ischaemic attacks as a cause of isolated recurrent vertigo

•  (1) Learn to do the head-impulse

In the patient having a first ever attack of acute isolated spontaneous vertigo

test.  If positive think of labyrinthitis. (2) If negative always think of cerebellar infarction. • Think of cerebellar infarction in patients with vascular risk factors or cerebellar signs

In the patient who is generally off balance
• Think of bilateral vestibular loss due
to gentamicin, normal pressure hydrocephalus, early cerebellar ataxia, early progressive supranuclear palsy, sensory peripheral neuropathy and orthostatic tremor in the patient who is off balance for no obvious reason. Beware the posterior fossa tumour.

In the patient who is off balance:
• 1 Think of gentamicin vestibulotoxicity. • 2 Think of normal pressure hydrocephalus. • 3 Beware of the posterior fossa tumour or
malformation / early cerebellar ataxia. • 4 Think of early progressive supranuclear palsy • 4 Think of orthostatic tremor. • 5 Consider spinal cord or peripheral nerve pathology.

In the lightheaded patient (+/collapse/falls) think of:
• Low blood pressure due to various
reasons • Postural hypotension • Neurocardiogenic syncope • Carotid sinus syndrome • Aortic stenosis • Arrythmias

References
• Diagnosis and management of
vertigo - Clinical Medicine Vol 5 No 2 March/April 2005 GM Halmagyi • Assessment and treatment of dizziness J. Neurol. Neurosurg. Psychiatry 2000;68;129-134 G M Halmagyi and P D Cremer