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Vertigo Clarification

Anand Swaminathan, MD FAAEM and Evie Marcolini, MD
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Nurses Edition Commentary

Lisa Chavez, RN and Kathy Garvin, RN
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EM:RAP 2018 04 April Written Summary 535 KB - PDF

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Braedon H. -

It was mentioned that if hearing loss is present, you have to be concerned of a central cause such as AICA. What about Meniere's? Doesn't that have similar features? What do you recommend?

Evie M., M.D. -

If the patient exhibits new hearing loss, especially if it is on the side of the abnormal head impulse test (opposite the direction of nystagmus) it can represent an early sign of AICA (anterior inferior cerebellar artery) stroke, and actually is more often the case rather than a peripheral cause such as viral labyrinthitis. This is the etiology of the "HINTS plus" test, where we add unilateral hearing loss to the battery of tests that comprise HINTS. This, of course is not applicable if the symptoms are fluctuating or pre-existing, such as with a patient who has pre-existing Meniere's. Meniere's is a progressive disease associated with vertigo, tinnitus, fluctuating hearing loss and fullness of the ear, and ultimately can manifest permanent hearing loss, but the fluctuating and progressive nature of Meniere's is differentiated from acute, new hearing loss when performing the "HINTS plus" exam on the patient with Acute Vestibular Syndrome. This question reinforces the importance of doing a thorough neurologic exam, and full history and physical when evaluating these tricky patients. And as always, if your patient has risk factors and/or a good story for stroke, bring in the reinforcements and obtain a neurology consult and/or MRI.
Here are some references:
Newman-Toker DE et al. HINTS outperforms ABCD2 to screen for stroke in acute continuous vertigo. Acad Emerg Med 2013;20:987-96
Lee H. Audiovestibular loss in anterior inferior cerebellar artery territory infarction: a window to early detection? J Neurol Sciences 2012;313:153-59
Newman-Toker DE. Symptoms and signs of neuro-otologic disorders. Continuum Lifelong Learning Neurol 2012;18(5):1016-40

Edmund T. -

Sorry for my late reply. I understand when to apply the HINTS exam now but my question is for those presenting with triggered or episodic vertigo. What kind of work up, if any, do these patient's need in the emergency department?

Anand S., M.D. -

Edmund - this will really depend on what you think the cause is. Many of the causes are benign (episodic vestibular syndrome - panic attacks, reflex syncope, meneire's disease. triggered vestibular syndrome - BPPV, orthostasis) but some are serious (episodic - TIA, SAH, Dysrhythmia). So the workup really depends on what you suspect based on the patient's presentation, risk factors etc.

robert k., mr -

dudes, .....

check this youtube video from a canadian neurologist.

he explains the hints exam the best of anyone and makes it simple to understand.

https://youtu.be/84waYROlI4U

Evie M., M.D. -

Robert,
Thanks for sending this link. Dr. Johns is one of the best teachers of these concepts, and has a lot of great video material online if you search for it. His videos give several examples of pathology that are rare to come by.
Evie

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