dizzy dizzy

http://www.hitrecord.org/records/813005

This is tough one, I would love to discredit all dizziness but there's that sinking feeling in my gut that I just killed my patient...

Here's the low down:

Acute Vestibular Syndrome vs. Stroke

What is an acute vestibular syndrome?

-vestibular neuritis

-vestibular migraine

-multiple sclerosis

I. Auditory symptoms aren’t as helpful

  A. non-specific to central vs. peripheral

      1. hearing changes could be related to infarction of anterior inferior cerebellar artery (AICA)

II. Onset is important

  A. sudden onset suggest neuritis

III. Trauma

  A. concern for dissection of vertebral artery

IV. Neck Pain

  A. associated with stroke

V. Neuro deficits

  A. trouble swallowing

  B. slurred speech

  C. diplopia are concerning symptoms: posterior circulation syndrome

VI. Age > 50 is concerning

VII. Vascular risk factors (I know I know, this is risk stratification rather than clinically significant for disease)

  A, age

  B.  bp

  C. smoking

  D. H/O CVA or MI

  E. DM

  F. a-fib

  G. atherosclerosis

  H. CHF

PEARL: Dizziness, neck pain, headache= 3 most common complaints in dissecting vertebral artery

HPI: H/O otitis, Rx (aminoglycosides, etc.), HIV, depression, recent viral syndrome

This next part is going to blow your mind, in 2011 some smart people over at John Hopskins found that physical exam is just as sensitive as imaging!!!

HINTS exam (head impulse/head thrust, nystagmus, test of skew)

-Impulse Normal (patient is able to fixate)= stroke ; abnormal means vestibular cause

   This one is a little hard to do, and even hard to see the results. I like Scott Weingart's idea of using your phone to slow down the action

-Fast-Alternating: gaze evoked nystagmus (look right, beat right; look left, beat left)= stroke

-Refixation on Cover Test: ocular misalignment (skew)= stroke

-INFARCTS= if any 1 of the 3 is found on exam, think stroke!

CT is not helpful, but is 1^st line of defense

MRI is only 83% sensitive…and if you do get an MRI, go big and get a MRA with neck.

http://www.webmm.ahrq.gov/case.aspx?caseID=63

Dix-Hallpike- not helpful. It doesn’t really confirm peripheral vertigo, and it DOES NOT rule-out central causes. 

Dr Michelle Lin's blog offers a great flash card you can print out as well as videos (can you tell I REALLY like her blog yet?)

References: 

Kerber, KA, Brown, DL, Lisabeth, LD, Smith, MA, Morgenstern, LB. Stroke Among Patients with Dizziness, Vertigo, and Imbalance in the Emergency Department. Stroke, 2006 August 31; 37:2484-2487. doi: 10.1161/​01.STR.0000240329.48263.0d

Tarnutzer AA, Berkowitz AL, Robinson KA, Hsieh YH, Newman-Toker DE. Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome. CMAJ. 2011 Jun 14;183(9):E571-92.

sagittal sinus thrombosis

This was a new one to me...

So let's say you have a patient present to the ED, she had a new onset H/A 2 days ago that was "the worst ever" and went to another ED. No history of migraines. Not responsive to migraine cocktail. Ancillary workup unremarkable, CT and LP unremarkable. Patient was D/C home with pain control.
She presents to you now in obvious distress. Physical exam reveals no focal deficits. What's your differential?
Differential Diagnosis:
Pseudotumor Cerebri (Idiopathic Intracranial Hypertension)
Spinal Headache
Sagittal Sinus Thrombosis (What?!?!)

Quick and dirty:
A. rare, and presentations are variable
B. most common among female, 30ish year olds
C. venous structures in the brain get obstructed, this can lead to increased pressure of capillary beds and end up with cerebral edema.
D. Risk Factors:
   1. prothrombic conditions (MOST COMMON)
   2. head injury
   3. all those things that put you at risk for hypercoagulable states
       a. OCP
       b. pregnancy
       c. malignancy
       d. infection
E. MRI-venous
  1. CT is normal in 30% of cases
F. D-Dimer is not specific (if elevated it can support, but negative does not rule-out)


References:

Ferro, JM, & Canhão , P. Etiology, clinical features, and diagnosis of cerebral venous thrombosis. In: UpToDate, Basow, DS (Ed), UpToDate,Waltham, MA, 2012.

Pathak, V, Rendon, ISH, Freddo, L, Dangal, MM. Sagittal Sinus Thrombosis in a Young Migraineur. New York Medical Journal, Fall 2009.