Approach to the patient with acute vestibular symptoms, an overview.  

acute vestibular symptomsacute vestibular symptoms

Patient With Acute Vestibular Symptoms – Introduction

Acute vestibular symptoms are commonly encountered both in acute and outpatient settings. Symptoms can present with classic features of the underlying etiology. However, it is not uncommon to encounter patients with mild or a predominantly unspecific clinical picture, concealing an underlying life-threatening condition such as stroke. For that reason, vertigo and dizziness represent a significant challenge to practitioners, for which knowledge of the diagnosis and management of vestibular syndromes is required.

This article will address the clinical problem and offer an overview of the diagnosis and and risk stratification of patients with vertigo and dizziness, with a focus on the scoring systems used for aiming in the decision of further diagnostic measures for the detection of central causes of acute vestibular syndromes.

Definitions

Symptoms: (1)

Vertigo is defined as the sensation of the spinning motion of self or the environment when no actual movement of that nature occurs.

Dizziness is the sensation of spatial disorientation that is not accompanied by a sensation of movement in space.

Unsteadiness is the sensation of positional instability, independently of the actual position of the body.

Many definition systems and diagnostic algorithms have focused on determining patients’ defining symptoms. Although individuals can feel and report those different sensations, it is usually inaccurate to classify different etiologies under a specific symptom. For that reason, recent approaches to the diagnosis and management of dizziness and vertigo have instead focused on the evolution and characteristics of symptoms.

Syndromes:

The TITRATE algorithm (1) has identified several syndromes according to the timing and triggers associated with symptom onset and progression.

Episodic vestibular syndrome (EVS) is recurrent, occurring in different episodes over time independent of the time involved in each episode (the latter is a factor utilized to further characterize the syndrome).

Acute vestibular syndrome (AVS) is sudden in onset and continuous over time.

Both syndromes can be further characterized according to the presence or not of known or identified triggers, into spontaneous and triggered EVS and spontaneous or post-exposure AVS.

Spontaneous EVS includes peripheral or extra-vestibular etiologies such as Meniere’s disease, vasovagal response, cardiac arrhythmias, myocardial ischemia/infarction, pulmonary embolism, hypoglycemia, and carbon monoxide toxicity. A concerning central cause includes transient ischemic attack (TIA).

Triggered EVS accounts for peripheral and extra-vestibular causes such as benign peripheral paroxistical vertigo (BPPV) or orthostatic hypotension. A central cause of triggered EVS could be an ischemic stroke.

Spontaneous AVS could be produced by peripheral causes like new-onset Meniere’s disease and central causes such as stroke, encephalitis, hydrocephalus, or, more rarely, cerebral tumors and demyelinating disease.

Post-exposure AVS include etiologies like medications (antiepileptic drugs, aminoglycoside antibiotics), perilymphatic fistula, toxic substances (CO, illicit drugs), head trauma (with or without secondary injuries like skull base fractures or intracranial hemorrhages), or cervical trauma (whiplash injury, vertebral artery dissection).

Epidemiology

Vestibular symptoms are a frequent concern among patients presenting to emergency departments, accounting for 4% of annual consultations. (2) The estimated 1-year prevalence for vertigo presentations is 4.9%. (3)

Most of the etiologies of vertigo are peripheral in nature. (2) Estimates for the prevalence of central causes are around 12-23% in different series. (2, 4) Missed diagnosis of central vertigos ranges from 20-35%, which reflects the challenge that this group of symptoms poses to physicians. (5)

Several epidemiological studies assert that the incidence of vertigo and dizziness increases with age (6), and the lifetime prevalence of vestibular symptoms ranges from 3-30%. (7)

Annual costs due to this clinical syndrome account for $3.9 billion/year in a study performed in US emergency departments. (8)

Etiology

Vertigo and dizziness can be classified as central or peripheral according to the anatomical structures involved in the production of the symptoms. Central vertigo refers to the structures that pertain to the central nervous system (CNS) and peripheral to those that affect the vestibular nerves or the vestibular apparatus. (9)

Central Peripheral
Stroke and TIA Benign Peripheral Paroxysmal Vertigo (BPPV)
Demyelinating disease Meniere’s disease
CNS tumors Acute vestibulopathy (vestibuliar neuritis or laberynthitis)
Otosclerosis
Cholesteatoma
Perilymphatic fistula

Approach to the patient

Risk factors associated with life-threatening causes of acute vestibular symptoms

Risk factors for life-threatening etiologies of vestibular symptoms are mainly gathered by proper and thorough interrogation of the patient’s history of current presentation, comorbid conditions, exposure to substances, tobacco use and medications, traumatic events, and family history. Important risk factors for central causes include age above 60, hypertension, smoking, diabetes, cardiovascular disease, immunologic disease, oncologic disease, and comorbid thrombotic conditions (such as thrombophilia). (10-12)

Risk factors are not always evident or reported by patients. High clinical suspicion for undiagnosed conditions that pose a risk for central disease should be had, especially for elderly patients, patients with poor medical attention, and those with psychiatric conditions mimicking acute vestibular syndromes.

Symptomatology

As mentioned earlier, patients with acute vestibular syndrome represent a challenge to every physician. A complete clinical history documenting the evolution of symptoms, either acute or chronic in nature, the situation of presentation and triggers, characterization of changes in presentation, description of the patient’s sensation, and associated features is paramount.

A complete review of comorbidities, allergies, concomitant medications, family history, tobacco or illicit drug use, and traumatic history should be performed, with a special focus on risk factors for life-threatening central causes of vestibular symptoms.

Full documentation of vital signs should be performed.

A complete neurological examination should be done, focusing on localizing neurological signs, vestibulo-ocular examination, lower cranial nerves, and motor, sensory, and cerebellar function. Examination of the outer ear is important to assess for any local alteration, such as ear infections. Cardiovascular and respiratory examinations, including an ECG, should be done.

Laboratory parameters to assess for metabolic, cytologic, electrolytic, and acid-base disorders should be performed.

Clinical stratification of patients with acute vestibular syndrome

The use of clinical tools to help clinicians assess whether vertigo and dizziness are of central or peripheral etiology have been developed in the last decades. However, they differ in sensitivity and specificity, even if performed by trained subjects.

The PoiSe Algorithm is a novel approach to diagnosing and managing dizziness and vertigo based on the EMVERT trial and previous literature on the field. (13)

The algorithm corresponded to an overall accuracy of 71% in diagnosing acute dizziness and vertigo, with a sensitivity of 94% for cerebrovascular events and a specificity above 95% for the six most common vestibular disorders.

The system’s main goal is to determine which patients need further workup to diagnose a central cause of dizziness and vertigo, mainly a cerebrovascular event.

The first level assessment consists of screening for signs and symptoms that suggest a central cause of symptoms (for ex., stroke or transient ischemic attack). A complete workup for central causes should be performed if one or more positive answers were encountered.

The screening includes:

  • Sensory deficit to the limbs or face.
  • Paresis of the face or limbs.
  • Visual impairment.
  • Speaking difficulties (dysarthria or aphasia).
  • HINTS examination with one central sign.
  • Central pattern of nystagmus.
  • Impairment in the ability to walk.

Cardiovascular risk factors for stroke and TIA are valid for suspicion of central vascular causes. The ABCD score reflects the sensitivity involved in recognizing such risk factors in the context of a patient with acute vestibular syndromes. (14)

  • Age ≥60 years = 1
  • Blood pressure • B systolic ≥140 or diastolic
  • ≥/90 = 1
  • Clinical features: unilateral weakness = 2; speech disturbance without weakness = 1; any other symptom = 0.
  • Duration of symptoms <10 min = 0; 10–59 min = 1; ≥60 min = 2.
  • Diabetes present = 1.

A score of 2 or more implicates an increased sensitivity for detecting stroke. (15)

In the neurological examination, a special focus on vestibulo-ocular performance is assessed with the HINTS+ exam, which reflects a physiopathological alteration to the neuraxis implicated in central causes of vestibular symptoms: (16-18)

  • Head impulse test.
  • Skew deviation.
  • Central pattern nystagmus.
  • Hearing loss.

The sensitivity of one or more HINTS+ findings is higher than cerebral MRI in the early stages of posterior fossa strokes. (16)

The main goal of these scoring systems is to stratify patients at risk for central causes of vestibular symptoms. These should be used as a guide for the detection of evidence supporting central causes of vestibular signs and symptoms and aim in the decision of further diagnostic testing.

Once a presumptive diagnosis is made, neuroimaging, close observation, and advanced vestibular assessment are the mainstay for definitive diagnosis.

Diagnostic Tools

MRI has the highest sensitivity among imaging studies for diagnosing central causes. It permits an evaluation of parenchymal and vascular structures associated with the development of strokes, such as diffuse-weighted imaging sequences for the detection of cerebral ischemia and contrast-enhanced imaging in the case of cerebral tumors or other differentials of central causes. CT-brain has poor sensitivity for posterior fossa ischemic disease (~17%) and high sensitivity for hemorrhagic disease. (16, 19, 20)

A new MRI at 48 hours after symptom onset may be useful for patients with a high clinical yield of central surrogates but initial negative imaging studies. (20)

Video-oculo nystagmography implies a more specific study for evaluating acute vestibulo-ocular findings in the neurological examination. It can yield a sensitivity of almost 100% for detecting central causes of vestibular symptoms, requiring the evaluation of patients in centers with specialized care. (21)

Close inpatient observation is warranted for those patients with negative findings in imaging studies but clinical findings of central causes of acute vestibular symptoms, keeping in mind that MRI could yield negative results in the early stages of posterior fossa strokes.

Differential Diagnosis

This list is not extensive. The differential diagnosis includes seemingly different conditions that may mimic each other and represent a challenge to every physician encountering a patient with acute vestibular syndromes. (22) A complete description of each disease entity will be treated in individual articles.

  • Non-specific dizziness.
  • Pre-syncope.
  • Acute coronary syndrome.
  • Pulmonary embolism.
  • Cardiac arrhythmias.
  • Carbon monoxide toxicity.
  • Meniere’s disease.
  • Benign Peripheral Paroxistic Vertigo.
  • Acute vestibular neuritis.
  • Transient Ischemic Attack.
  • Ischemic Stroke.
  • Hemorrhagic Stroke.
  • Posterior Fossa Tumors.
  • Demyelinating diseases, such as multiple sclerosis.
  • Migrainous vertigo.
  • Otosclerosis
  • Perilymphatic fistula.
  • Cholesteatoma.
  • Electrolytic imbalances.
  • Metabolic imbalances (hypoglycemia).
  • Neuroinfections.
  • Hydrocephalus.
  • Cerebral tumors.
  • Vertebral artery dissection.

Disclosures:

The author does not report any conflict of interest.

Disclaimer:

This information is for educational purposes and is not intended to treat disease or supplant medical professional judgment. Physicians should follow local policy regarding the diagnosis and management of medical conditions.

References

  • Newman-Toker DE, Edlow JA. TiTrATE: a novel, evidence-based approach to diagnosing acute dizziness and vertigo. Neurologic clinics. 2015 Aug 1;33(3):577-99.
  • Zwergal A, Dieterich M. Vertigo and dizziness in the emergency room. Current Opinion in Neurology. 2020 Feb 1;33(1):117-25.
  • Neuhauser HK. Epidemiology of vertigo. Current opinion in neurology. 2007 Feb 1;20(1):40-6.
  • Huq MR, Saleheen S, Jannat M, Haque M, Hossain S, Sarker I, Malik SS, Ahmed A, Begum A, Barman KK, Hannan MA. Epidemiological and Clinical Study of Vertigo in a Tertiary Care Hospital of Bangladesh. Journal of Advances in Medicine and Medical Research. 2022 Sep 14:54-60.
  • Qiu T, Dai X, Xu X, Zhang G, Huang L, Gong Q. A prospective study on the application of HINTS in distinguishing the localization of acute vestibular syndrome. BMC neurology. 2022 Dec;22(1):1-0.
  • Colnaghi S, Rezzani C, Gnesi M, Manfrin M, Quaglieri S, Nuti D, Mandalà M, Monti MC, Versino M. Validation of the Italian version of the dizziness handicap inventory, the situational vertigo questionnaire, and the activity-specific balance confidence scale for peripheral and central vestibular symptoms. Frontiers in neurology. 2017 Oct 10;8:528.
  • Murdin L, Schilder AG. Epidemiology of balance symptoms and disorders in the community: a systematic review. Otology & Neurotology. 2015 Mar 1;36(3):387-92.
  • Saber Tehrani AS, Coughlan D, Hsieh YH, Mantokoudis G, Korley FK, Kerber KA, Frick KD, Newman‐Toker DE. Rising annual costs of dizziness presentations to US emergency departments. Academic Emergency Medicine. 2013 Jul;20(7):689-96.
  • Ozono Y, Kitahara T, Fukushima M, Michiba T, Imai R, Tomiyama Y, Nishiike S, Inohara H, Morita H. Differential diagnosis of vertigo and dizziness in the emergency department. Acta oto-laryngologica. 2014 Feb 1;134(2):140-5.
  • Wang Y, Liu J, Cui Z, Yan L, Si J. Analysis of risk factors in patients with peripheral vertigo or central vertigo. The Neurologist. 2018 May 1;23(3):75-8.
  • Dommaraju S, Perera E. An approach to vertigo in general practice. Australian family physician. 2016 Apr;45(4):190-4.
  • Brandt T. Miscellaneous central vestibular disorders. InVertigo 2003 (pp. 241-246). Springer, New York, NY.
  • Filippopulos FM, Strobl R, Belanovic B, Dunker K, Grill E, Brandt T, Zwergal A, Huppert D. Validation of a comprehensive diagnostic algorithm for patients with acute vertigo and dizziness. European Journal of Neurology. 2022 Oct;29(10):3092-101.
  • Navi BB, Kamel H, Shah MP, Grossman AW, Wong C, Poisson SN, Whetstone WD, Josephson SA, Johnston SC, Kim AS. Application of the ABCD2 score to identify cerebrovascular causes of dizziness in the emergency department. Stroke. 2012 Jun;43(6):1484-9.
  • Newman‐Toker DE, Kerber KA, Hsieh YH, Pula JH, Omron R, Saber Tehrani AS, Mantokoudis G, Hanley DF, Zee DS, Kattah JC. HINTS outperforms ABCD 2 to screen for stroke in acute continuous vertigo and dizziness. Academic Emergency Medicine. 2013 Oct;20(10):986-96.
  • 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 Nov 1;40(11):3504-10.
  • Kattah JC. Use of HINTS in the acute vestibular syndrome. An Overview. Stroke and vascular neurology. 2018 Dec 1;3(4).
  • Newman-Toker DE, Curthoys IS, Halmagyi GM. Diagnosing stroke in acute vertigo: the HINTS family of eye movement tests and the future of the “Eye ECG”. InSeminars in neurology 2015 Oct (Vol. 35, No. 05, pp. 506-521). Thieme Medical Publishers.
  • Lawhn-Heath C, Buckle C, Christoforidis G, Straus C. Utility of head CT in the evaluation of vertigo/dizziness in the emergency department. Emergency radiology. 2013 Jan;20(1):45-9.
  • Saber Tehrani AS, Kattah JC, Kerber KA, Gold DR, Zee DS, Urrutia VC, Newman-Toker DE. Diagnosing stroke in acute dizziness and vertigo: pitfalls and pearls. Stroke. 2018 Mar;49(3):788-95.
  • Saber Tehrani AS, Kattah JC, Kerber KA, Gold DR, Zee DS, Urrutia VC, Newman-Toker DE. Diagnosing stroke in acute dizziness and vertigo: pitfalls and pearls. Stroke. 2018 Mar;49(3):788-95.
  • Chan Y. Differential diagnosis of dizziness. Current opinion in otolaryngology & head and neck surgery. 2009 Jun 1;17(3):200-3

See Also

Nephrolithiasis in Adults

Distal Radius Fractures in Adults

Diagnosis and Management of Vulvovaginitis

Diagnosis and Management of Anaphylaxis in Adults

Acute Uncomplicated Pyelonephritis in Adults

About the Author

Franco Cuevas, MD
Franco Cuevas is a physician who graduated from the National University of Córdoba, Argentina. He practices general medicine in the Emergency Department at Sanatorio de la Cañada, Córdoba. His focus is on writing medical content to improve physicians' access to relevant medical information for daily practice. He has participated in some research projects and has a special joy in teaching and writing about medical concepts.

Follow us

Leave a comment

Your email address will not be published.


*