Medical and Nonstroke Neurologic Causes of Acute, Continuous Vestibular Symptoms

The Journal of Emergency Medicine

Newman‐Toker

2018

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Background Dizziness, a common chief complaint, has an extensive differential diagnosis that includes both benign and serious conditions. Emergency physicians must distinguish the majority of patients with self-limiting conditions from those with serious illnesses that require acute treatment. Objective of the Review This article presents a new approach to diagnosis of the acutely dizzy patient that emphasizes different aspects of the history to guide a focused physical examination with the goal of differentiating benign peripheral vestibular conditions from dangerous posterior circulation strokes in the emergency department. Discussion Currently, misdiagnoses are frequent and diagnostic testing costs are high. This relates in part to use of an outdated, prevalent, diagnostic paradigm. The traditional approach, which relies on dizziness symptom quality or type (i.e., vertigo, presyncope, or disequilibrium) to guide inquiry, does not distinguish benign from dangerous causes, and is inconsistent with current best evidence. A new approach divides patients into three key categories using timing and triggers, guiding a differential diagnosis and targeted bedside examination protocol: 1) acute vestibular syndrome, where bedside physical examination differentiates vestibular neuritis from stroke; 2) spontaneous episodic vestibular syndrome, where associated symptoms help differentiate vestibular migraine from transient ischemic attack; and 3) triggered episodic vestibular syndrome, where the Dix-Hallpike and supine roll test help differentiate benign paroxysmal positional vertigo from posterior fossa structural lesions. Conclusions The timing and triggers diagnostic approach for the acutely dizzy patient derives from current best evidence and offers the potential to reduce misdiagnosis while simultaneously decreases diagnostic test overuse, unnecessary hospitalization, and incorrect treatments.

Section: A New Diagnostic Paradigmmentioning

confidence: 99%

A New Diagnostic Approach to the Adult Patient with Acute Dizziness

The Journal of Emergency Medicine

Newman‐Toker

2018

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“…47,48 Rare causes of an isolated AVS include cerebellar hemorrhage, 49 thiamine deficiency, 50 and various autoimmune, infectious, or other metabolic conditions. 47 A key concept is understanding the distinction between symptoms that are exacerbated (dizzy at baseline, worse with movement) versus triggered (not dizzy at baseline, dizziness develops with movement). Patients with an AVS typically experience worse dizziness with head movement (exacerbation), such as when performing the Dix-Hallpike maneuver, but this is not a sign of BPPV.…”

Section: Acute Vestibular Syndromementioning

confidence: 99%

Acute Dizziness

2019

Semin Neurol

Dizziness is a common chief complaint with an extensive differential diagnosis that includes both benign and serious conditions. Physicians must distinguish the majority of patients who suffer from self-limiting conditions from those with serious illnesses that require acute treatment. The preferred approach to the diagnosis of an acutely dizzy patient emphasizes different aspects of the history to guide a focused physical examination, with the goal of differentiating benign peripheral vestibular conditions from dangerous posterior circulation strokes. Currently, misdiagnoses are frequent and diagnostic testing costs are high. This partly relates to use of an outdated diagnostic paradigm. This commonly used traditional approach relies on dizziness “symptom quality” or “type” (vertigo, presyncope, disequilibrium) to guide inquiry. It does not distinguish benign from dangerous causes and is inconsistent with current best evidence. A better approach categorizes patients into three groups based on timing and triggers. Each category has its own differential diagnosis and targeted bedside approach: (1) acute vestibular syndrome, where bedside physical examination differentiates vestibular neuritis from stroke; (2) spontaneous episodic vestibular syndrome, where associated symptoms help differentiate vestibular migraine from transient ischemic attack; and (3) triggered episodic vestibular syndrome, where the Dix-Hallpike and supine roll test help differentiate benign paroxysmal positional vertigo from posterior fossa structural lesions. The “timing and triggers” diagnostic approach for the acutely dizzy derives from current best evidence and offers the potential to reduce misdiagnosis while simultaneously decreasing diagnostic test overuse, unnecessary hospitalization, and incorrect treatments.

“…The most frequent dangerous cause is posterior circulation ischemic stroke, generally in the cerebellum or brainstem. A small minority are due to multiple sclerosis [20]. Rare causes of an isolated AVS include cerebellar hemorrhage [21], thiamine deficiency [22], and various autoimmune, infectious, or other metabolic conditions [20].…”

Section: Acute Vestibular Syndrome (Avs)mentioning

confidence: 99%

“…A small minority are due to multiple sclerosis [20]. Rare causes of an isolated AVS include cerebellar hemorrhage [21], thiamine deficiency [22], and various autoimmune, infectious, or other metabolic conditions [20]. Importantly, although nystagmus is implicit in the classic definition of AVS, some patients with AVS will present without nystagmus, especially those with a stroke etiology.…”

Section: Acute Vestibular Syndrome (Avs)mentioning

confidence: 99%

Neuro-otologic Emergencies: A Practical Approach

Neurological Emergencies

2019

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Diagnostic Keys• Stroke is an important cause of acute dizziness in the emergency setting.• Small posterior strokes can present with an isolated acute vestibular syndrome. • Physical exam findings often allow for a confident and specific diagnosis and reliably discriminate between peripheral and central disorders. • Early (<48 hours of onset) neuroimaging even with DW-MRI may miss up to 15-20% of posterior circulation strokes presenting as isolated dizziness. • Sudden sensorineural hearing loss (SSNHL) can be diagnosed with careful physical examination.