The Big 3 of Vertigo

Transcription

1 They feel it, you see it, few know it: Common vertigo conditions seen, but rarely diagnosed Peter Johns MD, FRCPC University of Ottawa The Big 3 of Vertigo BPPV Vestibular neuritis Cerebellar Brainstem stroke syndromes 1

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4 Under diagnosis Over investigation Inappropriate treatment Physician and patient frustration How can we decrease Dizziness NYD? 4

5 Two very common causes of vertigo WAY under diagnosed BPPV BPPV =Posterior Canal BPPV PC BPPV 5

6 BPPV =Posterior Canal BPPV PC BPPV 6

7 Anterior semicircular canal Posterior semicircular canal Horizontal semicircular canal 7

8 Horizontal Canal BPPV 8

9 Have you diagnosed HC BPPV? Horizontal Canal BPPV HC BPPV Common Under diagnosed If confused with PC BPPV, will lead to treatment failure with the Epley maneuver If confused for central positional vertigo, will lead to over investigations (CT/MRI/referrals etc.) 9

10 352 patients presenting to emergency department with vertigo or unsteadiness ½ of the patients had BPPV 39% of those patients had HC BPPV 1/5 of all patients with vertigo/unsteadiness had HC BPPV 10

11 2682 patients with BPPV seen in vertigo clinics in Italy 38% HC BPPV 110 pediatric patients with BPPV Average age 13 years old 34% HC BPPV 11

12 How many cases of HC BPPV did I diagnose in the first decade of teaching how to diagnose and treat BPPV? 0 12

13 How do they present Sounds like BPPV Maybe not sure which side turning in bed causes the vertigo May get severe episode of vertigo merely by turning head while upright but Dix Hallpike is negative Or 13

14 Do you think you have seen HC BPPV? 14

15 Early take home points for HC BPPV This is not a positive Dix Hallpike test! This is not PC BPPV, and Epley maneuver will not help them! This is likely HC BPPV and it needs another bedside test to diagnose it, and another maneuver to cure it The supine roll test How to do it 15

16 On testing both sides with supine roll test Nystagmus towards ground = Geotropic (towards the Ground) OR Nystagmus away from ground =Apogeotropic (Away from ground) 16

17 Which is the affected ear? Left or right? One side shows more intense nystagmus Nystagmus on that side is pointing at the Affected ear Other ear is the Good ear 17

18 Left Geotropic HC BPPV 18

19 Good Affected 19

20 Left Apogeotropic HC BPPV 20

21 Good Affected Regular BPPV PC BPPV, only one side is positive, and one kind of nystagmus seen-easy! 21

22 L Geotropic HC BPPV R Geotropic HC BPPV L Apogeotropic HC BPPV R Apogeotropic HC BPPV How to cure it HC BPPV? Ask Dr. Mauro Gufoni 22

23 Gufoni Maneuver Lie them on their side two minutes Turn their head 45 degrees two minutes Sit them up L Geotropic HC BPPV R Geotropic HC BPPV L Apogeotropic HC BPPV R Apogeotropic HC BPPV 23

24 Geotropic HC BPPV Apogeotropic HC BPPV 24

25 Geotropic HC BPPV lie them on their Good ear turn their head towards the Ground Apogeotropic HC BPPV lie them on their Affected ear turn their head Away from the ground 25

26 Left Geotropic HC BPPV Good Affected Geotropic HC BPPV lie them on their Good ear turn their head towards the Ground 26

27 Left Apogeotropic HC BPPV Good Affected Apogeotropic HC BPPV lie them on their Affected ear turn their head Away from the ground 27

28 Summary for HC BPPV Not uncommon! Suspect it if Dix-Hallpike negative or horizontal nystagmus seen Need to distinguish it from regular BPPV Know that Epley maneuver doesn t work for HC BPPV Don t over investigate it Cure it or refer it 28

29 56 year old woman 6 hours of constant dizziness Nausea, no vomiting Worsens when she changes position 29

30 56 year old woman No headache/neck pain Feels slightly unsteady, but able to walk No hearing changes or tinnitus No face or limb weakness or paresthesias 56 year old woman No diplopia/dysarthria/dysphagia/dysphonia/dysmetria No spontaneous or gaze evoked nystagmus 30

31 56 year old woman HINTS plus exam? No nystagmus, so can t do HINTS plus Dix-Hallpike and supine roll tests? Could think about it, but both are negative 31

32 The second most common cause of dizziness (after BPPV) The most common central cause of vertigo Rarely diagnosed by front line clinicians Nobody dies of it Ask about previous episodes 1 st episode of vertigo- 10 years ago Maybe 15 or 20 episodes in the last 10 years Two previous visits to ED for dizziness NYD in past 5 years Usually lasts around 30 mins., the two previous visits were longer episodes CT head done 1 year ago normal Seen by ENT and neurology No diagnosis 32

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34 History of migraines headaches? Yes, onset of migraine headaches in teenage years, had many a year. Approaching menopause, had fewer headaches but started getting dizzy spells. Ever get migraine type headache before, during or after her dizzy spells? Sometimes Photophobia or phonophobia with dizzy spells? At times, yes Visual symptoms? Sometimes shimmering lights or spots All leading to this question: Would you say of the 15 or 20 dizzy spells you ve had in the last 10 years, how often do you have either a headache typical of your migraines, or photophobia/phonophobia or visual symptoms associated with the dizzy spells? Pretty often" So would you say less than half the time, or more than half the time? Oh more than half the time Vestibular migraine 34

35 VM described 20 years ago One year prevalence of 2.7% Only 10% had been told it was VM 37% rated their problem as moderate to very large problem 23% had gone to ED/hospital for their problem 35

36 How to make the diagnosis Many episodes of vertigo Hx of migraines At least half the episodes have dizziness plus a migraine feature Doesn t sound like something else Diagnostic Criteria 36

37 Diagnostic findings? No bedside test such as Dix Hallpike or HINTS plus No diagnostic imaging findings Nystagmus Mostly not seen even during acute presentation May see various kinds of nystagmus 37

38 Why missed so often? Up to half the episodes of vertigo can be isolated vertigo Some never have a headache associated with the dizzy spell Many are in the TIA time frame Isolated vertigo lasting minutes or hours TIA?? 38

39 Transient isolated motor deficit 20% minor stroke on imaging Transient isolated vertigo 1.4% minor stroke on imaging Most common non TIA diagnosis was migraine 39

40 Less than 24 hours of vertigo Of those who had a stroke 78% had either dysarthria, focal weakness, limb ataxia, sensory disturbances, headache, neck pain Would have been picked up by Big 3 approach 275 patients with posterior circulation stroke 45 had transient neurological attack (TNA) including 23 isolated vertigo Only 1 in 27 with TNA sought medical attention before stroke 40

41 Treatment for Vestibular Migraine Poorly studied Expert opinion is treat acute episode and prophylaxis same as migraine headache My practice metoclopramide in 1 litre of normal saline Why diagnose vestibular migraine? False positive Dx of TIA over investigation, over treatment Affects patient confidence, employment, lifestyle, insurance 41

42 Conclusion Sounds like BPPV, but Dix Hallpike negative/ horizontal nystagmus seen Supine Roll Test Dx HC BPPV If recurrent episodes of vertigo with history of migraines Explore history for diagnosis of Vestibular Migraines Conclusion Making few Dizziness NYD diagnoses will Decrease needless investigations/referrals Avoid unnecessary treatment Apply appropriate treatment Make you and your patient feel better 42

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