Author: Jacob Lotstein, MD (EM Chief Resident, Maine Medical Center) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Brit Long, MD (@long_brit, EM Chief Resident at SAUSHEC, USAF)

The dizzy patient is both a common complaint and source of anxiety for the emergency physician. The differential diagnosis is broad and riddled with dangerous pathology. It is further complicated by the fact that patients have a challenging time providing an accurate history regarding this chief complaint, leading to difficulty narrowing down your considerations. Lastly, there are numerous commonly-held false beliefs, leading to controversy and confusion amongst practitioners. This article is meant to simplify the approach to the dizzy patient in a practical manner, focusing on the “can’t miss” diagnoses that fall along this path.

First, many approaches to the workup of the dizzy patient focus on separating your patients into “pre-syncope vs vertigo” before starting your workup. This makes sense since dizziness can describe either of these two entities; however, they are completely different in etiology and require different evaluations. However, as noted above, to the best of their abilities many patients often cannot tell you reliably which of these two entities they are suffering from. Thus instead of starting off by asking the patient to tell you which of these two camps they fall into (ie, asking “Do you feel light-headed or is the room spinning?”), it is often more prudent to allow yourself to make that decision based on the patient’s description of the symptoms and exam. This article will focus primarily on the vertiginous patient due to the large scope of grouping the evaluation of both vertigo and presyncope into one paper.

Initial Evaluation

Upon entering the room, as always, check the basics. What does your patient look like? Are they hemodynamically stable? Vital signs (including blood sugar) will often hint towards an etiology of the dizziness. For example, tachycardia, hypotension, hypoxia, or hypoglycemia might point towards pre-syncope (as opposed to vertigo). On the other hand, a patient who cannot even sit upright during the exam due to ataxia or open their eyes during the history due to the spinning sensation and nausea makes vertigo a more likely culprit. Of note, while orthostatic vital signs are often acquired to try to differentiate these two entities, they are nonspecific and present in a large portion of individuals, particularly elderly, regardless of their chief complaint. In addition to a basic survey of the patient and vital signs, consider an EKG and place the patient on the monitor at this time. At this point, consider and treat immediately threatening conditions. These include hypoglycemia, hemorrhage, sepsis, and arrhythmias.

History of Present Illness

As emergency physicians, we must continue to first consider the most dangerous and immediately threatening conditions. There are several symptom complexes that can present with dizziness that require immediate consideration. These high-risk symptom complexes and their potential diagnoses include:

–Dizziness + Headache/Neck Pain: Subarachnoid hemorrhage, Hemorrhagic stroke, Vertebral artery dissection

–Dizziness + Chest pain/Shortness of breath: Acute coronary syndrome, Pulmonary embolism

–Dizziness + Palpitations: Arrhythmia

–Dizziness + Focal neurologic deficits: Stroke, Ramsay-Hunt syndrome

If the patient denies these symptoms on your initial evaluation, continue with your typical history-taking as you normally would. Pay particular attention to the duration, timing, and triggers of the symptom of dizziness as this is a key part of narrowing the differential diagnosis.

Pre-syncope or light-headedness: Dizziness is triggered with upright positioning or walking with little or no symptoms with movement of the head only (eg turning the head back and forth while sitting or lying down). This entity is described as a sensation similar to when one stands up too quickly. A basic history, review of systems, and physical exam will often help the practitioner come to a list of potential etiologies although. The initial differential diagnosis is broad including:

-Poor oral intake

-GI fluid losses (diarrhea, vomiting)

-Hemorrhage/Anemia (GI bleed, ectopic pregnancy, ruptured AAA)

-Neurogenic (vasovagal episode, post-micturition/defecation)

-Arrhythmia

-Metabolic disturbance (hypoglycemia, renal failure, electrolyte disturbance)

-Infection/sepsis

-Medication (any new medications or changed dosages, diuretics, antihypertensives, antiarrhythmics, anticholinergics)

The vertiginous syndromes: Dizziness is described as a spinning sensation associated with nausea.

Acute vestibular syndrome: Fairly abrupt in onset, continuous, and often lasts days to weeks. It may improve with time. The differential includes:

-Stroke

-Vestibular neuronitis

-Multiple sclerosis

-Post-traumatic

Spontaneous episodic vestibular syndrome: Composed of episodes without any trigger lasting minutes to days. While it may worsen with movement, the sensation of vertigo persists despite complete stillness on the part of the patient. The differential includes:

-Vestibular migraine

-Acute labyrinthitis

-Vestibular neuronitis

-Meniere’s disease

-Seizures

-Transient ischemic attack

Triggered episodic vestibular syndrome: Episodes are triggered by movement in the head or body. Between episodes, the patient is completely asymptomatic. The differential diagnosis is short including:

-Benign paroxysmal vestibular syndrome

-Orthostasis

Chronic vestibular syndrome: Dizziness is described as a spinning sensation associated with nausea. It is gradual in onset, continuous, lasts week or months (or longer), and often worsens with time. The differential includes:

-Intracranial mass (tumor or abscess)

-Drugs/toxins (antiepileptics, aminoglycosides, loop diuretics, salicylates)

-Vestibular neuronitis

History of present illness, part II

As previously stated, the majority of this article will focus on the evaluation of the vertiginous patient. The primary concern of the emergency practitioner in this case should be whether or not this may represent a posterior stroke due to the importance of timely diagnosis and treatment of this entity, particularly if the patient is a candidate for thrombolysis. Some aspects of the patient’s description of the vertigo make this more likely.

High Risk Factors:

Gait disturbance (OR 5.9-9.3) 1, 3-5, 8, 10

Focal neurologic complaints suggesting cerebellar dysfunction (Diplopia, Dysarthria, Dysphagia, Dystaxia, Vertigo)1, 4, 8

Moderate Risk Factors

Sudden onset of symptoms 3-6

Headache3, 5

Low Risk or Non-predictive Factors

Positional symptoms 1

Isolated vertigo (0.7% risk of CVA) 2, 6

Auditory symptoms6

As noted in the table, positional symptoms have not been shown to be predictive of the risk of stroke. This is a commonly-held misconception: that if dizziness worsens with movement then it is likely to be BPPV. However, all vertigo will worsen with movement, regardless of the cause. BPPV is unique in that while at rest, the patient is completely asymptomatic. This feature does point towards a low risk of stroke, unlike a worsening of symptoms with movement. Additional low-risk factors including auditory symptoms and isolated vertigo (ie lack of other neurologic deficits), both pointing towards a peripheral cause of the symptoms.

In terms of the patient’s medical history, both age greater than 60 and prior stroke have been noted to be moderate risk factors for stroke as a cause of the vertigo.1, 4, 6-11

Physical Exam

Once the history-taking is complete, move on to your physical exam. A thorough neurologic exam is a key part of the work-up of the dizzy patient including cerebellar and cranial nerve testing in addition to the basic exam. The HiNTS exam is a set of physical exam maneuvers published in 2009 that can be considered as a part of your neurologic testing as well, especially in the patient with acute vestibular syndrome. These examinations are difficult to describe in a succinct manner, and we would recommend that the reader watches a video demonstration either on YouTube or at (http://emcrit.org/misc/posterior-stroke-video). This exam compromises three specific tests:

1) Head impulse: In this test, the physician is testing the vestibulo-ocular reflex. The patient’s head is thrust quickly from pointing to one side back to center with the patient’s eyes focused on the physician in front of them. In a peripheral lesion (such as Meniere’s disease), this will be abnormal on one side, indicated by a corrective saccade as opposed to the normal smooth eye movements. In a central lesion, there will be no effect of this reflex. This is commonly confusing because an abnormal test indicates a benign pathology whereas a normal test (in the setting of vestibular dysfunction such as vertigo and nystagmus) can indicate central pathology such as a stroke. Of note, this test should only be used in patients with acute vestibular syndrome.

2) Nystagmus: Direction-changing horizontal nystagmus or any vertical or rotatory nystagmus indicates a central lesion, while unidirectional horizontal nystagmus is indicative of a peripheral lesion.

3) Test for Skew: As the patient’s eyes are each covered and uncovered separately while focusing on an object (such as the physician’s nose), they should (in the absence of a central lesion), remain focused on the same spot with no vertical correction. In a central brainstem lesion with an imbalance of vestibular tone, they will deviate in a vertical manner. This test is specific for central pathology, but not sensitive.

Risk Category Physical Exam Features

High Risk Features · Focal Neuro Deficit (OR 5.9; Sensitivity 64%, Specificity 100%)1, 4, 8 · Severe Truncal Ataxia (Sensitivity 33%, Specificity 100%)4 · Normal Head Impulse Test in Setting of Acute Vestibular Syndrome (+LR 18.3, Sensitivity 85%, Specificity 95%)9, 18 · Direction-changing, rotatory or vertical nystagmus (Sensitivity 38%, Specificity 92%)18 · Positive skew deviation (Sensitivity 30%, Specificity 98%)18 · Abnormal HiNTS (Sensitivity 88-100%, Specificity 85-98%)4, 18-21 Low Risk Features · Normal Neurological Exam (-LR 0.49, OR 0.05) 2, 4 · Abnormal head impulse test (-LR 0.16) 18 · Normal HiNTS exam (-LR 0-0.03) 4, 19, 20 Non-predictor · Dix-Hallpike maneuver (OR 0.0-1.2) 1

A recent publication in Journal of Emergency Medicine by Dr. Edlow and Dr. Newman-Toker recommends asking 5 questions in the evaluation of vertigo with acute vestibular syndrome:22

Is the patient unable to sit or stand help? Does the patient have a focal finding on neurological examination? Does the patient have worrisome spontaneous or gaze-evoked nystagmus? Does the patient have negative HIT? Does the patient have skew deviation (vertical eye misalignment)?

If the answer is yes to any of the above, further evaluation for stroke is recommended.22

Diagnostic Imaging

As the last step in evaluating your dizzy patient, one must consider diagnostic imaging for an acute stroke. Although most providers realize the limited sensitivity of CT scanning for acute stroke, many may not realize how low the sensitivity for acute posterior stroke is with MRI scanning, even within the first 24 hours. In the table below are listed the sensitivities for the various scanning modalities available to use for posterior strokes. As noted, the gold standard at this time is diffusion-weighted imaging on MRI.

MRI DWI · Sensitivity within 3 hours (≥41%)13, 16 · Sensitivity within 24 hours (≥83%)13, 14, 16 · Up to 23% may be missed in the first 48 hours9, 14, 17 MRI T2 Imaging · Sensitivity within 24 hours (40%)15 CTA · Sensitivity within 6 hours (26-61%)13, 16 CT Without Contrast · Sensitivity within 3 hours (10%)23 · Sensitivity within 24 hours for posterior CVA (41%)13



Summary

The dizzy patient can be a difficult patient encounter with multiple dangerous diagnoses to consider. While many patients are unable to reliably describe whether they are suffering from presyncope or vertigo (and thus may require an evaluation for both entities), some will provide historical clues or descriptors that will allow a narrowing of the differential at this initial step. As always, immediate life-threatening conditions must be considered such as arrhythmias, hemorrhage, or sepsis. Many of these conditions will be readily apparent on either the initial vital signs (including blood glucose and telemetry/EKG) or with basic labs (such as a CBC and a BMP). If the patient describes true vertigo, a thorough neurologic exam is key and the HiNTS exam (best in the patient with acute vestibular syndrome), while difficult for the inexperienced practitioner, has been shown to have excellent sensitivity and specificity for acute stroke. With practice, one should find him/herself comfortably able to navigate the treacherous waters of the “weak and dizzy” and be able to safely decide on the appropriate disposition of these patients.

References / Further Reading:

1) Navi BB, Kamel H, Shah MP, et al. Rate and predictors of serious neurologic causes of dizziness in the emergency department. Mayo Clin Proc. 2012;87(11):1080-8.

2) Kerber KA, Brown DL, Lisabeth LD, Smith MA, Morgenstern LB. Stroke among patients with dizziness, vertigo, and imbalance in the emergency department: a population-based study. Stroke. 2006;37(10):2484-7.

3) Kase CS, Norrving B, Levine SR, et al. Cerebellar infarction. Clinical and anatomic observations in 66 cases. Stroke. 1993;24(1):76-83.

4) Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009;40(11):3504-10.

5) Newman-Toker DE, Kattah JC, Alvernia JE, Wang DZ. Normal head impulse test differentiates acute cerebellar strokes from vestibular neuritis. Neurology. 2008;70(24 Pt 2):2378-85.

6) Gomez CR, Cruz-Flores S, Malkoff MD, Sauer CM, Burch CM. Isolated vertigo as a manifestation of vertebrobasilar ischemia. Neurology. 1996;47(1):94-7.

7) Lee H, Kim BK, Park HJ, Koo JW, Kim JS. Prodromal dizziness in vestibular neuritis: frequency and clinical implication. J Neurol Neurosurg Psychiatr. 2009;80(3):355-6.

8) Chase M, Joyce NR, Carney E, et al. ED patients with vertigo: can we identify clinical factors associated with acute stroke? Am J Emerg Med. 2012;30(4):587-91.

9) Morita S, Suzuki M, Iizuka K. False-negative diffusion-weighted MRI in acute cerebellar stroke. Auris Nasus Larynx. 2011;38(5):577-82.

10) Kerber KA, Zahuranec DB, Brown DL, et al. Stroke risk after nonstroke emergency department dizziness presentations: a population-based cohort study. Ann Neurol. 2014;75(6):899-907.

11) Lee CC, Su YC, Ho HC, et al. Risk of stroke in patients hospitalized for isolated vertigo: a four-year follow-up study. Stroke. 2011;42(1):48-52.

12) Wasay M, Dubey N, Bakshi R. Dizziness and yield of emergency head CT scan: is it cost effective? Emerg Med J. 2005;22(4):312.

13) Fiebach JB, Schellinger PD, Jansen O, et al. CT and diffusion-weighted MR imaging in randomized order: diffusion-weighted imaging results in higher accuracy and lower interrater variability in the diagnosis of hyperacute ischemic stroke. Stroke. 2002;33(9):2206-10.

14) Hwang DY, Silva GS, Furie KL, Greer DM. Comparative sensitivity of computed tomography vs. magnetic resonance imaging for detecting acute posterior fossa infarct. J Emerg Med. 2012;42(5):559-65.

15) Linfante I, Llinas RH, Schlaug G, Chaves C, Warach S, Caplan LR. Diffusion-weighted imaging and National Institutes of Health Stroke Scale in the acute phase of posterior-circulation stroke. Arch Neurol. 2001;58(4):621-8.

16) Chalela JA, Kidwell CS, Nentwich LM, et al. Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison. Lancet. 2007;369(9558):293-8.

17) Morita S, Suzuki M, Iizuka K. False-negative diffusion-weighted MRI in acute cerebellar stroke. Auris Nasus Larynx. 2011;38(5):577-82.

18) Tarnutzer AA, Berkowitz AL, Robinson KA, et al. Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome. CMAJ. 2011 Jun 14;183(9):E571-92.

19) Chen L, Lee W, Chambers BR, et al. Diagnostic accuracy of acute vestibular syndrome at the bedside in a stroke unit. J Neurol. 2011 May;258(5):855-61.

20) Newman-Toker DE, Kerber KA, Hsieh YH, et al. HINTS outperforms ABCD2 to screen for stroke in acute continuous vertigo and dizziness. Acad Emerg Med. 2013 Oct;20(10):986-96.

21) Batuecas-Caletrio A, Yanez-Gonzalez R, Sanchez-Blanco C, et al. Peripheral vertigo versus central vertigo. Application of the HINTS protocol. Rev Neurol. 2014 Oct 16;59(8):349-53.

22) Edlow J and Newman-Toker D. Using the physical examination to diagnose patients with acute dizziness and vertigo. Journ Emerg Med. 2016, in press: http://dx.doi.org/10.1016/j.jemermed.2015.10.040.

23) Chalela JA, Kidwell CS, Nentwich LM, et al. Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison. Lancet. 2007;369(9558):293-8.