1. Inpatient Evaluation of The “Dizzy” Patient
Jaclyn Laine DO, APBN
OhioHealth Neurological Physicians

2. Objectives: Identify key history leading to more accurate diagnosis
Distinguish clinical features of central versus peripheral etiology
Determine the “red flag” symptoms for pathologic vertigo

3. Anatomy Peripheral Vestibular System
Vestibular aparatus: semicircular canals, utricle saccule and CN VIII- vestibular nerve
Central Vestibular System
Vestibular nuclei at the ponto-medullary junction, cerebellum, midbrain

4. Consensus Definitions for Vestibular Symptoms
Vertigo
The sensation of self -motion with no motion is occurring or distorted self motion during normal head movements
Dizziness
The sensation of disturbed or impaired spatial orientation without a false or distorted sense of motion
Unsteadiness
Feeling of being unstable without a particular directional preference
Oscilopsia
The false sense that the visual surround is oscillating

5. Timing is the most important detail !
Acuity
Acute or chronic
Provoking nature
Spontaneous or positional
Episodic or prolonged
Seconds, minutes, hours, days
Fluctuations or no symptoms between episodes

6. Key Points in Past Medical history
History of migraine
With aura or vertigo induced by movement in surrounding
Atherosclerotic risk factors
CAD, known orthostasis
Head trauma
Medications: lithium, TCA’s ototoxic antibiotics, alcohol, AED’s

7. Features pointing towards central etiology:
Exam with postural and gait instability
Nystagmus can be any direction, however
Sometimes reverses direction when patient looks in the direction of slow component
Features pointing towards peripheral etiology
Aural fullness, Hearing loss, tinnitus
Sensation of instability - not wanting to walk
Exam with normal posture and gait
Nystamgus torsional horizontal, not purely vertical, doesn’t reverse direction

8. Vertigo is not continuous for more than a few weeks.
Even with permanent lesions the central nervous system adapts to the defect so that vertigo subsides over several weeks.
Constant dizziness lasting months is usually psychogenic, not vestibular.
Some patients who say they have constant dizziness for months actually mean that they are susceptible to frequent episodic dizziness.

9. Common Categories of Vestibular Symptoms
Acute, Spontaneous and prolonged
(Acute vestibular syndrome)
Episodic, positional
(BPPV and central mimics)
Episodic spontaneous
(Vestibular migraine, Meniere's, TIA )
Chronic unsteadiness -with/without oscilopsia
(Oscilopisa at rest – nystagmus brain stem lesion)
(Oscilopsia with head motion - bilateral vestibular failure)

10. New onset dizziness Common causes and dangerous Mimis
BENIGN Dangerous Mimics
Seconds to hours- episodic
BPPV TIA, Cardiac Arrythmia
Orthostatic hypotention MI, PE, GI bleed
Reflex syncope Aortic dissection, atrial myoxma
Days to weeks- continuous
Viral labrynthitis Brainstem/ cerebellar stroke
Vestibular neuritis Bacterial labrinthitis/mastoiditis
Medication toxicity Herpes zoster oticus Anticonvulsants Brainstem encephalitis
Wernicke Syndrome
Toxic – lithium, etoh withdrawal CO exposure

11. Key points
Vestibular dizziness is always exacerbated or provoked by head movement
At least in the acute phase
No matter if peripheral or central in origin
Clear reproducible triggers for non-exertional vestibular symptoms generally indicate a benign cause
Not all patients with new onset seizure require MRI

12. Case #1
25 year old woman presented with recent episodic dizziness and headache. This occurred spontaneously one or twice a week during the prior 6 weeks. Lasting 5-10 minutes. No associated neurologic symptoms were present. The pain was located behind the left year and present throughout the last six weeks without variation of severity.
Personal history of episodic migraine holocephalic, nausea, throbbing, dizziness, family history of migraine, no history of vascular risk factors

13. Case Considerations Sounds like Vestibular migraine
Young, female, personal history of migraine with “dizziness”
However non-flucuating continuous head pain with referral to ear?
What questions are missing?
History of trauma
History or recent illness, fever, ear drainage
History of aural fullness, tinnitus hearing changes

14. Further questioning
Reveals head and neck trauma from carrying a mattress about 2 months ago
Continuous headache and lack of fluctuating points to a fixed structural pathology
Imaging
CTA head and neck with attention to temporal bones
looking for mastoiditis, vascular structural pathology
Imaging revealed a vertebral artery dissection

15. Quick Tips Protective P’s If old and recurrent Periodic, Prolonged
Recurrent Stereotyped episodes over years
If symptoms are acute/subacute
Painless
IF painful
Red flags:
sudden < 30 minutes, severe, sustained >72 hours

16. Points to Remember Deadly D’s Indicating vascular brainstem symptoms
Diplopia
Dysarthria
Dysphagia
Dysmetria ( clumsiness)
Dysethesias (specific facial numbness)
Drop attacks
Down is up distortions ( room inverted)
NO dyspnea ( cardiopulmonary)
NO deafness ( vascular inner ear)

17. Case 2#
71 year old man presented with several months of episodic spinning, lightheadedness and imbalance
Last episode occurred for 10 seconds when her got our of been. He sat down and felt normal within in 20 seconds
He has been awakened by a spinning sensation
A more recent spell was described at lightheadness with standing in line at the grocery store
Neurological Exam and imaging normal, cardiac work up with Echo and EKG normal
Dix halpike showed nystagmus with left head position
Vestibular rehab improved symptoms, however continued to have symptoms walking

18. His continued symptoms warranted investigation and with orthostatic vital signs were not significant
Tilt table revealed BP to 75 systolic with normal HR and BP
Blood pressure meds adjusted
Low dose fludrocortisone
Behavioral strategites
This illustrates that the original history described two types of “dizziness”

19. Case 3#
26 year old male presents with 3 days of recurrent, severe dizzy episodes with ear fullness and sensitivity to sound. some last for 30 seconds, some for 10 minutes. This is brought on by exertional activities. He moved to a new apartment in the last week.

20. Perilymph Fistula
Episodic dizziness without true vertigo
Associated with heightened hearing or loss of hearing
Provoked by coughing or vasovagal
Caused by head trauma, heavy lifting, SCUBA
Diagnosis: ENT, valsaval with nystagmus, MRI not usually helpful, temporal bone CT rules out other pathology,
Treatment: ENT
Strict bed rest
Possible surgery

21. Case #4 51 year old woman who noted sensation of her
right ear ‘being blocked’ this AM.
Now has ringing and decreased hearing The room then began to spin wildly   She became diaphoretic, nauseated and vomited
  The spinning lasted about 60 minutes, then abated
  She now has a sensation of residual dysequilibrium several hours later
When a patient presents with new onset seizures with a cluster seizures, this is still considered first time seizure and does not define epilepsy, or automatic indication for AED’s

22. Case #5
50 y/o woman suddenly feels overwhelming tilting sensation, feels her legs become rigid and abruptly falls to the ground Recovers to normal after a few seconds
Prior history at age 43 of single episode of tinnitus with dizziness lasting several hours with complete resolution

23. Diagnosis in both cases
Meniere’s
Both are characteristic variants

24. Meniere’s
  Two or more definitive spontaneous episodes of vertigo 20 minutes or longer
Audiometrically documented hearing loss on at least one occasion
  Tinnitus or aural fullness
  Other causes excluded

25. Probable Meniere's One definitive episode of vertigo
 Audiometrically documented hearing loss on at least one
occasion
 Tinnitus or aural fullness
Other causes excluded

26. Treatment Diazide diuretic Strict low Na intake Vestibular suppressant
Stress Reduction
In severe cases surgical management

27. Eye movement testing A word on nystagmus. . .
No one likes to interpret it
High Points:
Nystagmus that fatigues- peripheral
Persistent downbeat- central
Pathologic Gaze evoked nystagmus
Vertical ( central)
Asymmetric
Present within 30 degrees of primary gaze

28. Case 6
65 year old female with history of mild imbalance and more episodes of vertigo when lying in bed at night.
Examination shows:
subtle downbeat nystagmus when gazine right and left
Dix hallpike in both directions triggers downbeat nystagmus only
Where is the most likely localization?
A: cerebellum
B:lateral semicircular canal
C: vestibular nerve right
D: saccule

29. Cerebellum
Gazed evoke downbeat nystagmus
Persistent positional downbeat nystagmus
Despite central etiology- cerebellar lesions can cause prominent positional symptoms

30. Conclusions
Initial history for subjective sensation and associated symptoms is key in establishing appropriate differential
Always perform eye movement testing, coordination testing, and gait testing
Timing of symptoms is more important than subjective description