Decoding Acute Vestibular Syndrome
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The document discusses the diagnosis and management of acute vestibular syndrome in emergency settings through three case studies. It highlights the importance of determining whether dizziness is due to pre-syncope or vertigo and outlines various diagnostic tests, including HINTS and Dix-Hallpike tests for differential diagnosis. Additionally, it covers the treatment options for conditions like BPPV, vestibular neuritis, and Meniere's disease.
Decoding Acute Vestibular Syndrome
- 1. Decoding Acute Vestibular Syndrome in Emergency Department - Dr Varun Patel
- 2. When a patient complaints of Dizziness -
- 3. Case 1 - A 52yr old female comes to ER with complaints of Sudden onset dizziness with 2 episodes of vomiting since she woke up from sleep 2 hrs back. She says that the dizziness is more on turning the head towards left and on lying or getting up from lying position. Patient is k/c/o Diabetes Type 2. Vitals are normal. ECG is normal. What is the probable diagnosis? How will you approach towards this patient?
- 4. Case 2 A 62yr old male patient comes to ER with history of Dizziness since 3 hrs with associated nausea. He says that he cannot balance himself while walking. The dizziness is not associated with change in position and is constant since the onset. He is k/c/o DM, HTN and Atrial Fibrillation. Patient is on multiple medications including Amiodarone and Ecospirin but is not on any anti-coagulants. What is the possible Diagnosis? What is the approach towards this patient?
- 5. Case 3 - A 29yr old female comes to ER with persistent dizziness since 15 days and associated hearing loss in left ear. Patient also complaints of buzzing sound in left ear since few days. No comorbidities. Patient has no history of imbalance while walking and neither does she complaint of any head trauma. What is the possible diagnosis? What is the approach towards this patient?
- 8. Pre-Syncope Start with ruling out Cardiac cause first. Check for following- 1. History of Palpitations 2. History of increase in Heart rate 3. History of Cardiac Arrhythmia in past 4. Get a 12 lead ECG (Look for Subtle signs – Know your Dangerous Rhythms) 5. Do a 2D-ECHO screen to look for structural causes
- 12. Diagnosis?
- 13. Diagnosis?
- 14. Diagnosis?
- 15. Brugada Types
- 21. Ataxia Do a complete Cerebellar examination to rule out Cerebellar involvement. Note : Some people might have a chronic Cerebellar symptoms which may make your examination even more difficult. Eg : A patient with previous PCA infarct comes with exaggerated vertigo symptoms but also says that he had baseline chronic vertigo for years after PCA infarct.
- 23. Sensory vs Cerebellar Ataxia
- 24. Romberg’s test to distinguish between Cerebellar and Sensory Ataxia This test has Sensitivity of 79% and Specificity of 80% to differentiate Sensory Ataxia from Cerebellar Ataxia
- 25. Sensory Ataxia
- 26. Anatomy of Proprioceptive pathway
- 27. DDs for Sensory Ataxia
- 28. Cerebellar Ataxia - Causes
- 29. Cerebellar ataxia – Time dependent causes
- 31. True Vertigo 1st thing to do is differentiate between Peripheral and Central cause of Vertigo -
- 32. HINTS Exam -
- 33. HINTS vs MRI
- 34. When to Perform HINTS? It should be performed on patients who have persistent, ongoing Vertigo and Nystagmus lasting for Hours to Days (Acute variant).
- 35. Nystagmus- HINTS
- 37. Test of Skew - HINTS
- 40. HINTS
- 43. Peripheral vertigo – Duration related causes
- 44. Benign Paroxysmal Positional Vertigo (BPPV)
- 47. BPPV Presentation Classically, it will be episodic in Nature, sudden onset and Positional vertigo. Vertigo is typically triggered by changing position to affected side. Typical Age group is 50yrs.
- 48. Diagnosis of BPPV: Dix-Hallpike Test
- 49. Dix-Hallpike Interpretation Type of Nystagmus- 1. Rotatory Nystagmus: Posterior Canal BPPV (90%) 2. Horizontal Nystagmus: Lateral Canal BPPV (7%) 3. Vertical Nystagmus: Anterior Canal BPPV (1-3%) 4. No Nystagmus – Perform Pagnini-McClure test to look for Lateral Canal BPPV
- 52. BPPV Treatment: There are various modalities of treatments available based on canal involved: 1. Posterior Canal BPPV (Most common type) – a. Epley’s Maneuver (Success rate – 80%) b. Semont’s Maneuver (Success rate – 90.4%) Some trials suggest that there is no difference in success rate between the 2 maneuvers. We use Epley’s over Semont’s type because of sudden jerky movements in Semont’s type. Note: The recurrence rate within 1 year after both maneuvers is approximately 10-15%
- 53. Epley’s Manuever
- 55. BPPV Treatment: 2. Lateral Canal BPPV: (Diagnosed by Pagnini McClure Test) a. Barbecue roll Maneuver (Success Rate – Appx 75%) b. Gufoni Maneuver (Success Rate – 47.1%) We prefer Barbecue roll Maneuver as per current guidelines to treat Lateral Canal BPPV
- 57. In which cases will we perform a HINTS and a Dix-Hallpike test in same patient?
- 59. Other causes of Peripheral Vertigo
- 60. Other Causes of Peripheral Vertigo
- 61. Treatment of other causes of Peripheral Vertigo Acute Vestibular Neuritis – Steroids (Methylprednisolone) Migraine – NSAIDs, Triptans Menneire’s Disease – Diuretics (Acetazolamide), Betahistine Acoustic Neuroma – Surgical Excision of Tumour
- 62. Thank you