00:01
In this lecture, we'll talk about
the approach to vertigo.
00:05
And let's start with a case.
00:07
This is a 34-year-old
woman with dizziness.
00:10
She presents to the clinic urgently
for evaluation of her dizziness.
00:15
The patient reports that
she is awoken each morning
for the past week,
feeling very dizzy when sitting up,
rolling over in bed
or turning her head.
00:24
This comes and goes
but seems to be provoked
by moving or turning her head.
00:29
She says that the dizziness feels
like the room is spinning.
00:33
She closes her eyes
when this happens,
and it slowly subsides.
00:37
She denies problems with
weakness, numbness, tingling.
00:40
She has a history of
borderline hypertension,
which is being managed
with diet and lifestyle.
00:46
And she's only on a multivitamin.
00:48
She has no allergies
and denies a personal or
family history of symptoms
that prompted the presentation.
00:55
Neurologic exam shows normal
finger-to-nose and heel-to-shin.
00:59
She has no primary position
nystagmus
but when you turn her head,
she develops torsional nystagmus
and becomes severely dizzy.
01:08
So what's the most likely diagnosis?
Well, when we're
approaching this case,
as with any patient
who presents with dizziness,
step one is to look at
the patient description.
01:19
Is this dizziness described
as vertigo,
the room spinning or
spinning about the room?
Is the description more in line
for disequilibrium.
01:28
Imbalance or disbalance,
or problems with the drunkenness?
Or does the sound like
syncope or presyncope?
Lightheadedness or
feeling of being faint?
Hear the patient's description
sound squarely like vertigo.
01:41
The patient describes
that the room is spinning.
01:44
Our next step is to look
at the timeline of onset.
01:48
If we're dealing with
a vertigo problem,
a problem with the
vestibular function.
01:52
One of the helpful features
will be its timeline of onset.
01:56
This patient describes an onset
over about a week.
01:59
That's not acute onset over a day
or chronic onset over months,
this is subacute
over this one week.
02:06
We know that acute pathology
are things like
stroke, trauma,
and some intoxications.
02:12
Chronic pathology
or things like neoplasms
degenerative conditions,
or metabolic deficiencies.
02:18
In the subacute phase,
we worry about other things
and this will help us
to hone in on the right diagnosis.
02:24
The last are provoking factors
and this can be very helpful
when evaluating
a patient with
episodic or paroxysmal vertigo.
02:33
Here this patient's symptoms
are provoked
by head turning and sitting up,
and moving her head.
02:39
And that's very important
in establishing the diagnosis
for this patient.
02:44
So what is the most
likely diagnosis?
Is this cardiogenic syncope?
Labyrinthitis or
vestibular neuritis?
Post-infectious cerebellitis?
A brainstem stroke?
Or BPPV, Benign Paroxysmal
Positional Vertigo.
03:01
Well, this doesn't sound like
cardiogenic syncope.
03:03
Again, the patient's description is
really more consistent with vertigo
than syncope or disequilibrium.
03:09
Not all cases are so clear.
03:11
But in this case,
the description squarely points us
towards a vertiginous pathology.
03:18
What about labyrinthitis
or vestibular neuritis?
That causes vertigo.
03:22
But typically those patients present
with the acute vestibular syndrome.
03:26
That's acute onset of vertigo
and this was subacute in onset.
03:30
It is vertigo, and it is a
cause of persistent vertigo.
03:34
Patients just don't describe
episodic waxing and waning
of symptoms.
03:39
The vertigo begins and is persistent
until the time of presentation.
03:44
This patient presented
with episodes.
03:46
This was coming and going
over the last week
and induced by head turning.
03:50
So this is inconsistent
with a diagnosis
of labyrinthitis or
vestibular neuritis.
03:55
How about
post-infectious cerebellitis?
Those things can occur
at any point in time
in our subacute and onset.
04:02
That tends to be a
cerebellar problem.
04:04
This patient had normal
finger-to-nose, and heel-to-shin.
04:07
We didn't see those other
physical exam findings
that suggested an underlying
cerebellar abnormality.
04:14
This also doesn't sound like
a brainstem stroke.
04:17
Strokes are acute and onset, and
this patients onset with subacute.
04:21
Brainstem strokes
can cause vertigo,
but we often see other findings.
04:26
Long track findings like
weakness or hyperreflexia,
Crossed findings like
facial droop on one side
and weakness on the other.
04:33
And we have no other
associated neurologic deficits.
04:36
So this patient is
most likely suffering
from Benign Paroxysmal
Positional Vertigo, or BPPV.
04:43
That condition is exactly
what it sounds.
04:46
It's benign.
04:47
It is typically self-limited
though it can recur.
04:50
Its paroxysmal.
04:51
It occurs in episodes
where it comes and goes
over the course of a
week or several weeks
as in this patient.
04:57
It is positionally provoked.
04:59
So patients with
turning their head
or sitting up out of bed,
or lying down in bed
will induce a
severe episode of vertigo
that is severe during the episode
and then resolves over time.
05:10
And importantly, it's on the
differential diagnosis for vertigo,
not disequilibrium or syncope.
05:16
So this is a pretty
classic presentation for BPPV.