AM Report 10/17/16-Vertigo

Step 1: Determine whether patient is having Vertigo (spinning sensation) or Pre-Syncopal sensation (about to faint/fall) as the differential and workup will be different

Vertigo: is it Central vs. Peripheral?
  Remember that ALL vertigo gets worse with movement! 

Peripheral Vertigo

-BPPV
-Vestibular neuritis (remember that labrynthitis refers to involvement of the inner ear while neuritis refers to involvement of the vestibular nerve)
-Meniere disease
-Ramsay Hunt Syndrome
-Perilymphatic fistula
-Otitis media

Central Vertigo

-Cerebellar infarction
-Cerebellopontine tumor
-Multiple Sclerosis
-Vestibular migraine
-Brainstem ischemia
-Vertebrobasilar insufficiency

How can you tell the difference between Central and Peripheral Vertigo? 

vertigo-worksheet

If someone has ongoing vertigo and nystagmus, The HiNTs exam can be used to differentiate  posterior circulation syndrome (brainstem or cerebellar stroke) vs. vestibular neuritis

1)Head impulse testing-“normal” test is POSITIVE meaning no saccade/correction on head rotation
2)Nystagmus-Nystagmus that changes direction or pure vertical/torsional nytagmus
3)Test of skew –Covering and uncovering each eye and uncovered eye demonstrates quick vertical gaze corrections

1/3 POSITIVE tests indicates patient may have a posterior circulation stroke. 

Check out this EMcrit video that has a blog and video on how to do the HiNTs exam!
See original study here in Stroke Journal-on this study, the maneuver was 100 % sensitive and 96 % specific for posterior circulation stroke

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