Ver el código de «Vertigo»

==Background==
*Perception of movement (rotational or otherwise) where no movement exists 
*Pathophysiology 
**Mismatch or asymmetric activity of visual, vestibular, and/or proprioceptive systems
*Must distinguish peripheral from central cause
**Peripheral: 8th CN, vestibular apparatus
**Central: Brainstem, cerebellum

== Clinical Features==

{| class="wikitable"
|-
| 
| '''Peripheral'''
| '''Central'''
|-
| '''Onset'''
| Sudden
| Sudden or slow
|-
| '''Severity'''
| Intense spinning
| Ill defined, less intense
|-
| '''Pattern'''
| Paroxysmal, intermittent
| Constant
|-
| '''Aggravated by position/movement'''
| Yes
| Variable
|-
| '''Nausea/diaphoresis'''
| Frequent
| Variable
|-
| '''Nystagmus'''
| Horizontal and unidirectional
| Vertical and/or multidirectional 
|-
| '''Fatigue of symptoms/signs'''
| Yes
| No
|-
| '''Hearing loss/tinnitus'''
| May occur
| Does not occur
|-
| '''Abnormal tympanic membrane'''
| May occur
| Does not occur
|-
| '''CNS symptoms/signs'''
| Absent
| Usually present
|}

==Diagnosis==
===Sensitivity of Studies===
*Preference is for MRI due to greater sensitivity

{| class="wikitable"
| align="center" style="background:#f0f0f0;"|'''Test'''
| align="center" style="background:#f0f0f0;"|'''Sensitivity'''
|-
| [[EBQ:HINTS Exam|HINTS]]||100%
|-
| MRI (24hrs)||68.40%<ref name="mri">http://www.cnsuwo.ca/ebn/downloads/cats/2010/CNS-EBN_cat-document_2010-07-JUL-30_a-negative-dwi-mri-within-48-hours-of-stroke-symptoms-ruled-out-anterior-circulation-stroke_4494E.pdf</ref>
|-
| MRI (48hrs)||81%<ref name="mri"></ref>
|-
| CT non con||26%<ref>Chalela JA, Kidwell CS, Nentwich LM, et al. Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison. Lancet. 2007;369:293–8.</ref>
|}

[[File:Vertigo_and_Dizziness.jpg|thumb|Diagnostic algorithm Vertigo]]

===[[EBQ: HINTS Exam|HINTS Exam]]===
Proposed as method of distinguishing peripheral cause from cerebellar/brain stem CVA in the Emergency Department population <ref>http://ec.libsyn.com/p/a/d/d/add761f2a2847ea5/hints-exam.pdf?d13a76d516d9dec20c3d276ce028ed5089ab1ce3dae902ea1d01c0873ed8cc5fe910&c_id=2502227</ref><ref>http://www.ncbi.nlm.nih.gov/pubmed/18541870</ref><ref>http://hwcdn.libsyn.com/p/1/c/d/1cd6b38a89c178a1/diff-of-vertigo.pdf?c_id=2502226&expiration=1380995436&hwt=0a8bc67ea910e018a1543ebea192f668</ref>

{{HINTS Exam Procedure}}

{{HINTS Exam Primary Outcome}}

*''If any of the above 3 tests are consistent w/ CVA obtain full work-up (including MRI)''

== DDX ==
#Vestibular/otologic 
##[[Benign Paroxysmal Positional Vertigo (BPPV)]] 
##Traumatic (following head injury)
##Infection
###[[Labyrinthitis]]
###[[Vestibular Neuritis (Neuronitis)]]
###Ramsay Hunt syndrome 
#Syndrome 
##[[Meniere Disease]]
##Neoplastic 
##Vascular 
##Otosclerosis 
##Paget disease 
##Toxic or drug-induced: aminoglycosides 
#Neurologic 
##Vertebrobasilar insufficiency
###Head turning causes vertigo, [[Diplopia|diplopia]], dysarthria, b/l loss of vision, syncope
##Lateral Wallenberg syndrome 
##Anterior inferior cerebellar artery syndrome 
##Neoplastic: cerebellopontine angle tumors 
##Cerebellar disorders: hemorrhage, degeneration 
##Basal ganglion diseases 
##Multiple sclerosis 
##Infections: neurosyphilis, tuberculosis 
##Epilepsy 
##Migraine (basilar) 
##Cerebrovascular disease 
#General 
##Hematologic: anemia, polycythemia, hyperviscosity syndrome 
##Toxic: alcohol 
##Chronic renal failure 
##Metabolic 
###[[Thyroid Disease]] 
###[[Hypoglycemia]]

==Work-up==
#Glucose check 
#Full neuro exam
#TM exam 
#?CT/MRI - if symptoms consistent with central cause

==Management==
=== Peripheral ===

Symptomatic control
#Antihistamines: inhibit vestibular stimulation and vestibular-cerebellar pathways
##Meclizine (antivert) 25mg PO QID
##Diphenhydramine (benadryl) 25-50mg IM, IV, or PO q4hr
#Anticholinergics
##Scopolamine transdermal patch 0.5mg (behind ear) QID
#Antidopaminergics
##Metoclopramide 10-20 IV or PO TID

Cause Reversal
#Epley maneuver (see [[BPPV]])

===Central===
#R/O [[CVA]]
#MRI
#R/O Vascular insufficiency

== Disposition ==
*Most patients with peripheral vertigo can be discharged home
*All patients with central vertigo require urgent imaging and consultation while in the ED

==See Also==
*[[Dizziness]]
*[[EBQ:HINTS_Exam]]
*[[Cerebellar Stroke]]
*[[Stroke syndromes]]

== Source ==
*Tintinalli
<references/>
[[Category:Neuro]]
[[Category:Featured]]