00:01
This algorithm or flow diagram
really helps me to understand
the types of diagnoses that
we need to be concerned about
for any patient
presenting with vertigo.
00:10
The first thing we look at
is the timeline of onset.
00:13
Some patients present acutely
over hours with new onset vertigo.
00:18
Rooms spinning
and them spinning about the room.
00:20
And it remains
persistent over time.
00:23
We call that
acute persistent vertigo,
or the acute vestibular syndrome.
00:28
And we'll talk in a
subsequent lecture
about how to approach
those patients.
00:33
Other patients present acutely
with sudden onset of vertigo.
00:36
But it's episodic over time,
as we saw in this case,
with periods where
there's intense vertigo,
followed by remission
where the patient is normal.
00:47
And then finally, we can see
causes of chronic onset vertigo.
00:50
They're present slowly
over time often
with associated
cerebellar findings.
00:54
Nausea or vomiting,
or problems with balance,
or coordination, or postural tone.
00:59
And there's a certain
set of conditions
that we would consider
for chronic onset vertigo.
01:04
So the timeline
is onset is critical
in evaluating these patients
and honing in on a precise
differential diagnosis.
01:11
When we think about
episodic vertigo,
those paroxysmal paroxysms,
those episodes of vertigo
can be positionally provoked,
or spontaneous.
01:19
And that can also help us in
the differential diagnosis.
01:23
So let's think more about
each of these buckets,
each of these categories
of vertigo.
01:28
For chronic onset vertigo,
we think about medications.
01:31
They're one of the most common
causes of chronic vertigo
suffered by patients,
and many medications
can cause room spinning
or spinning about the room.
01:39
And an adjustment and dose
or removal of those
offending medications
is the treatment of choice.
01:44
We also think about mass lesions.
01:46
Slowly growing mass lesions
in the posterior fossa,
either a tumor,
an infectious process,
or an abscess,
can present in this way and
are important to to evaluate.
01:56
We think about mass lesions
within the cerebellum,
and brainstem and around
the vestibular nuclei,
and vestibular system,
as well as those
on the vestibular nerve
like vestibular schwannomas,
which can present with hearing loss
and varying degrees of vertigo.
02:12
When we think about
acute episodic vertigo,
that's vertigo that caused
that comes in episodes
and may be positionally provoked,
or spontaneous.
02:23
That categorization is important.
02:25
There are certain conditions
that are provoked
by selected maneuvers.
02:29
Head movement is one of the
most common propagating factors
and we see that with BPPV.
02:34
But we can also see
positionally induced vertigo,
that's vertigo that worsens
with standing
with orthostatic hypotension,
and vertebrobasilar insufficiency.
02:43
Were raising of an arm
or activation of an arm
can set off an episode
of vertigo.
02:49
That's different from spontaneous
onset episodic vertigo,
which would be seen in the case
of vestibular migraine
episodes of intense vertigo
that just come on spontaneously.
02:59
We can see this with
TIAs, arrhythmias,
ACS or Acute Coronary Syndrome,
and with manures disease
where we see
prominent hearing loss,
and sometimes tinnitus.
03:11
Let's talk about a couple of
examples of acute episodic vertigo
that you should know clinically
when evaluating
patients or vignettes.
03:19
The first as we saw
in this case is BPPV.
03:22
This is acute onset vertigo
that comes and goes over time
with episodes of
relapses and remissions.
03:29
There recurrent episodes
of severe vertigo
often the vertigo is
very severe for patients
and may be associated with
nausea, vomiting,
and problems with balance
and walking during the episode.
03:39
This is typically provoked
by head turning.
03:42
On examination, we see an
associated torsional nystagmus.
03:45
That's a rotary nystagmus
of the eyes,
as well as an upbeat nystagmus.
03:50
And that combination of torsion
and upbeat nystagmus with head turn
is diagnostic of this condition.
03:56
Episodes of vertigo
can be induced by maneuvers
and specifically the
Dix-Hallpike maneuver,
where the patient is brought from
a seated position to align position,
and then turning the head,
and lowering it below the bed
can induce that onset of
torsional and upbeat nystagmus,
and intense vertigo
for the patient.
04:14
And pathologically,
what we see going on in the
vestibular apparatus to cause this
is displacement of
calcium oxalate crystals
within the semicircular canals.
04:25
Those are dislodged.
04:26
They circulate
in the semicircular canals
and can cause
a sense of movement
without movement
actually occurring.
04:33
That process can drive
these episodes of vertigo.
04:36
Patients can have
clusters of episodes
when those calcium oxalate
crystals get dislodged,
that can remit for
sometimes months or years
and then recur over time.
04:47
And to treat this condition
we can use medications.
04:50
But the best treatment is
a physical exam maneuver
the Epley or
Brandt-Daroff maneuver,
which maneuver those
calcium oxalate crystals
to benign location in
the semicircular canal.
05:03
That treatment can be curative
at the time of the intervention.
05:06
And so that's something
we do in the clinic
or in the emergency department
to treat these patients that's
after a diagnosis has been made,
or would consider vestibular rehab
for long-term management
with repeated maneuvers over time.
05:20
So if BPPV is the example
of acute episodic vertigo
that is provoked by head movement.
05:26
Vestibular migraine
is acute episodic vertigo
that occurs spontaneously.
05:31
This is a headache syndrome.
and some patients have headache.
05:35
Others have an
acephalgic presentation
primarily with vertigo, and
very minimal or no head pain.
05:42
Patients describe
associated dizziness, vertigo
that may proceed or occur
during the headache phenomenon.
05:48
This occurs in episodes
like any migraine.
05:51
Patients have periods of
two to 72 hours of vertigo,
headache, and disability.
05:58
And this is followed
by periods of remission
or headache free,
and vertigo free intervals.
06:03
It may or may not be associated
with actual head pain.
06:06
And this is important.
06:07
Patients who present with
vertigo and head pain
we think about migraine,
but we need to consider those
acephalgic presentations.
06:15
Ultimately, this is a condition that
responds to antimigraine treatments.
06:21
And then our last
bucket of conditions
are the acute persistent vertigo's.
06:27
This is acute onset vertigo
room spinning
that doesn't come and go
in waves and episodes
but is persistent when it starts.
06:35
That acute vestibular syndrome
is a characteristic syndrome
that requires a different evaluation
from our other patients with vertigo
that we'll discuss
in a future lecture.
06:44
Our key goal as clinicians
is to differentiate
peripheral vertigo
from central vertigo.
06:50
And that is a key process
for evaluating patients
with the acute vestibular syndrome.
06:55
That's not our goal for evaluating
other causes of episodic vertigo.
06:59
And this underscores the
importance of characterizing
both the timeline of onset
whether it's acute or chronic,
and the evolution over time,
whether the patient
suffering persistent vertigo,
as in the acute vestibular syndrome,
or episodes of paroxysms,
as in the case of BPPV,
and vestibular migraine.