Senior author of "HINTS to diagnose stroke"
What is dizziness?
-Dizziness→ impaired perception of spatial orientation without vertigo
-Vertigo→ illusion of motion (spinning/non-spinning)
>Subjective (person)→ MC peripheral
>Objective (environment)→ MC central
-Oscillopsia→ 'world bounces'
>can’t read signs while walking
>B/L vestibular hypofunction
-Lightheadness, syncope→ LOC
-Imbalance→ severe truncal ataxia
Red flags associated sx
-Headache→ new
-Neck pain→ dissection
-AMS→ toxic
-CP→ PE & MI
Dizziness Ddx
“If you are sitting still with your eyes closed, are you still dizzy?”
Y→ Acute (Continuous) Vestibular Syndrome
N→ Episodic Vestibular Syndrome
Triggers
Positional, orthostatic, motion, auditory, visual, dietary
VPPB
-Position‑change + Short + Intense + Torsional
-Hx of TBI
-3-types
>Posterior→ vertical + MC BPPV + typical torsional nystagmus
>Horizontal→ lateral + turning + geotropic/apogeotropic nystagmus
>Superior→ vertical + rare + downbeat torsional pattern
-Otalgia
-Does not produce vertigo, but sense of imbalance
-Rare syphilis
Vestibular neuritis ≠ labyrinthitis
-Neuritis→ No hearing loss; labyrinthitis→ Y
-DDx: Neuritis→ PICA; Labyrinthitis→ AICA
-Post-viral, self-resolution wks-mo
Meniere disease
-VERT→ Vertigo (recurrent); Ear fullness (pressure); Ringing (tinnitus); Thump/low-tone hearing loss
-2015 Barany criteria→ ≥2 spontaneous vertigo episodes 20 min–12 hr
Vestibular migraine
-Episodic dizziness + migraine features + motion sensitivity + no hearing loss
-NOT req headache, and headache may come before, during, or after the vertigo
Persistent Postural‑Perceptual Dizziness (PPPD)
-Chronic + worse with motion/visual stimuli + triggered by a past event + normal exam
-Grows out when another problem ends (PMH of VN, BPPV, VM, TBI, psych)
Medications
-CALM EAR→ Cisplatin, Aminoglicoside, Loop diuretics, Malaria; Erythromycin, Asa, Redman (vancomycin)
-Others: taxane, bevacizumab
Perilymphatic Fistula (PLF) and Superior Canal Dehiscence (SCD)
-PLF→ sudden hearing loss + pressure-triggered vertigo after trauma
-SCD→ conductive hearing loss + sound-triggered vertigo + autophony
Carotid‑Cavernous Fistula (CCF)
-Pulsatile tinnitus + red eye + diplopia
-DSA
Acoustic neuroma
-U/L hearing loss + U/L tinnitus + chronic imbalance (not vertigo)
>CPA→ facial numbness
-NF2
VBI
-Vertigo + brainstem signs (diplopia/dysarthria/ataxia) + no hearing loss
-Sx occur at rest, NOT positional
≠Bow Hunter→ triggered ONLY by head rotation
>Dynamic imaging showing mechanical compression
-CTA w/ post circ stenosis
Stroke syndromes assoc w/ dizziness
-Hearing loss→ AICA
-Sensory→ Thalamus
-Vision→ PCA
-Quadriplegia→ Basilar
Physical exam
-POC & T° & BP
-Otoscopy→ cerumen, infection
-OH BP + telemetry→ cardiac source
-HINTS→ only w/ dizzy or nystagmus
>HINTS (SN100) vs MRI[<48h](SN88)→ to dx post circ stroke
>HINTS-plus→ add hearing test eval
-Cerebellar signs
-Gait
-Dix-Hillpike→ episodic and triggered by head movement
>Roll test→ positional, but ⊖Dix-Hillpike
-Romberg Test
-Fukuda test
HI-N-TS & IN-FA-RCT
Impulse Normal
Fast-phase Alternating
Refix on Cover Test
Head-Impulse
-Abnormal→ peripheral; Abnormal→ good
-Normal is absence of saccades
Nystagmus
-Horizontal-Torsional and unidirectional
-Look at other side decrease (Alexander's law)
Test of Skew
-No vertical skew
≠CN IV
Dix–Hallpike
Maneuver
Positive Dix Hallpike
Roll test
-Vertigo is positional, BUT ⊖Dix‑Hallpike
-Nystagmus looks horizontal
-Sx triggered by rolling in bed
-Suspect horizontal canal BPPV (geo = affected; apo = unaffected)
Romberg test
⊕→ verstibular dysf or sensory (peripheral neuropathy, post column disease)
*Sharpened (Tandem) Romberg test→ feet in tandem + arms crossed
Fukuda (Unterberger) test
-Marches in place, 50 steps
-Do: chronic imbalance; suspected unilateral vestibular loss
-Positive: ≥30° rotation→ peripheral vestibular weakness
Investigation
Labs
CBC→ sev anemia, infection
CMP→ all associated w/ dizziness/imbalance
POC→ hypo/hperG
Others:
A1c, OGTT, lipid profile (triglycerides), TSH, vit (B12 & D)
Lyme titers→ if vertigo + cranial neuropathies
HIV/RPR→ if encephalopathy, neuropathy, or atypical findings
Cardiac markers→ troponin, BNP
UDS + alcohol level
ILR/MCOT→ recurrent events
+/-routine-EEG
Neuroimaging
If classic BPPV→ no need; otherwise→ do it
Acute→ CTH & CTA H&N→ post circ infarcts & stenosis
bMRI D/H→ c/f central etiology
IAC-MRI→ U/L SNHL, U/L tinnitus
CT Temporal bone→ PLF, SCD, temporal bone trauma
Audiometry→ hearing loss, tinnitus, aural fullness, unexplained vertigo
Treatment
-NO long-term vestibular sedation→ blocks recovery
-General (vestibular sedatives)
>Meclizine PO 25q8
>Diphenhydramine PO/IV 25q8;
>Scopolamine TD 1.5q3d behind ear
>Diazepam 2q8 or lorazepam 0.5q8
-Medrol dose pack
-Vestibular rehabilitation therapy
VNeuritis/Labyrinthitis
<72h→ pred 60q24 for 5d
-Vestibular sedative→ meclizine
Meniere disease
-Low‑salt diet
-Limit caffeine/alcohol
-Thiazide‑type diuretics→ HCTZ 25q24
-Betahistine (no USA 2/2 lack efficacy)
-Steroids (intratympanic or PO) for flare‑ups
-ENT referral for refractory cases:
>Intratympanic gentamicin (caution: hearing risk)
>Endolymphatic sac decompression
Vestibular migraine
-Treat migraine
PPPD, Anxiety‑Related Dizziness
-SSRIs/SNRIs (sertraline/venlafaxine)
-CBT
>If anxiety, breathing techniques
-Treat underlying vestibular event that triggered PPPD
BPPV
-Reposition→ Epley, Semont, Gufoni
-Teach home Epley if recurrence
Epley maneuver
-Worse sx→ consider, sedative
-Rotate 1st to affected side
-Steps: 1) Turn head 45° toward affected ear. 2) Lie back into Dix Hallpike position. 3) Wait for symptoms to stop. 4) Turn head 90° to the opposite side. 5) Roll onto side (nose toward floor). 6) Sit up slowly
Home Epley
Semont maneuver
-Rotate 1st to non-affected side
-Steps: 1) Turn head 45° away from affected ear. 2) Drop rapidly to affected ear down side. 3) Hold 1 minute. 4) In one motion, swing to opposite side. 5) Hold 1 minute. 6) Sit up
Foster (Half‑Somersault)
-Steps: 1) Kneel and place head on floor. 2) Turn head 45° toward affected ear. 3) Lift head halfway (back straight). 4) Sit up
BBQ Roll (Lempert)
-Rotate 1st to affected side
-Steps: 1) Lie on back with head flexed 30°. 2) Turn head 90° toward affected side. 3) Turn head to midline. 4) Turn head 90° to opposite side. 5) Roll body onto stomach (face down). 6) Roll onto side and sit up
Gufoni
-Steps: 1) Sit upright. 2) Fall quickly to unaffected side. 3) After 1 min, turn head 45° downward. 4) Hold 2 min. 5) Sit up
-Appiani is when fall to affected side
Casani
Zuma‑e‑Maia
Yacovino
-Steps: 1) Sit upright. 2) Move quickly to head hanging supine position. 3) Hold 30 seconds. 4) Bring head up to chin to chest. 5) Sit up
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