Vertigo - Diagnosis and Management Summary
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Vertigo - Diagnosis and Management Summary

Illusion of motion of self or world 2/2 vestib dysfxn; a/w N/V, postural/gait instability. Important to distinguish: central vs peripheral

Hx/Exam: duration, episodic/persistent, triggers (position Δ), prior sx, assoc sx (5D’s for brainstem: dysarthria, diplopia, dysphagia, dysphonia, dysmetria). Orthostatics. Dix-Hallpike. HINTS.

HINTS+ Exam: Everything must be c/w peripheral to be reassuring. In acute vertigo, Sn 97% Sp 85% for stroke (better than MRI!)

 • Head Impulse (pt looks at your nose, passively rotate head. No saccade = ambiguous. Catchup saccade = peripheral).

 • Nystagmus (unidirectional e.g. always left-beating = peripheral; L-beating in L gaze, R-beating in R gaze, any vertical = central).

 • Test of Skew (cover one eye then other, any vertical skew/correction = central) 

Treatment: metoclopramide, prochlorperazine, meclizine (2 wks max, vestib suppression), lorazepam, diazepam AND Vestibular PT

Peripheral Vertigo:

 • Sx: Usually severe nausea, mild imbalance, hearing loss/tinnitus.

 • Ddx: benign positional paroxysmal vertigo (BPPV), infection (labyrinthitis, vesitibular neuritis, herpes zoster oticus), Meniere’s disease, vestibular migraine, otosclerosis, trauma (perilymphatic

fistula)

 • Imaging: if exam reassuring, none required

Central Vertigo:

 • Sx: Usually mild nausea, severe imbalance, rare hearing sx.

 • Ddx: cerebral infarction (vertebrobasilar ischemia), TIA, hemorrhage, toxic, cerebellopontine mass (vestib schwannoma, ependymoma, brainstem glioma, medulloblastoma, neurofibromatosis), multiple sclerosis, vestibular migraine

 • Imaging: MRI Brain W/WO, coronal DWI, MRA H&N



#Vertigo #Diagnosis #Management #treatment #neurology #central #peripheral
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