Vertigo
BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b3493 (Published 22 September 2009) Cite this as: BMJ 2009;339:b3493
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If Dr Barraclough still has doubts about the Head Impulse Test being able to distinguish cerebellar infarction from vestibular neuritis he should read: Newman-Toker DE, Kattah JC, Alvernia JE, Wang DZ. Normal head impulse testdifferentiates acute cerebellar strokes from vestibular neuritis. Neurology. 2008 Jun 10;70(24 Pt 2):2378-85.
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We very much enjoyed reading the informative and timely article by Barraclough and Bronstein on iterative process in relation to Vertigo and diagnosis of it’s underlying cause1. In the article “red flag†symptoms are mentioned that should prompt referall for further specialist attention. We report a case here that exemplifies the importance of clinicians individual heuristics based on prior experience in making correct diagnosis as mentioned in Dr Barraclough’s other article2.
A 70-year old female attended the A&E department because of severe vertiginous symptoms. This was clarified by the to be true vertigo of sudden onset some 6 days prior. Symptoms were worsened by movement, though not specifically related to a specific postural orientation and were severe enough to incapacitate the patient limiting her movement to crawling along the floor. She also had associated vomiting but did not have any hearing loss or otalgia. This initial episode lasted for approximately 3 hours before settling down, after which the patient described a general feeling of “imbalance†and unsteadiness when attempting to mobilise around her house. A second episode of vertigo that day, then prompted the patient to attend hospital. The medical history revealed AF, which had been DC cardio-verted and breast cancer treated with radical mastectomy some 3 years previously.
Assessment by the A&E F2 junior doctor was recorded as CNS being grossly intact with specific mention of no nystagmus, on extreme gaze, ataxic gait, pronator drift, normal power in all limbs and an appropriate differential diagnosis of labrynthitis, brainstem stroke and metastatic breast cancer. Further assessment by the medical team essentially confirmed these observations, though some unsteadiness on gait was additionally reported and the additional query of BPPV as a differential diagnosis raised. A CT head was arranged, which revealed only some generalized changes consistent with small vessel disease. When reviewed on the post take ward round, the patient was remarkably well and the presumptive diagnosis of labrynthitis was made in light of the CT scan and clinical findings.
The patient then got moved to our ward and was seen the day after admission. One of the team happened to be a trainee who has previously had the opportunity to work with Professor Bronstein and upon reviewing the history felt uneasy that the patient’s story “just didn’t fit with BPPVâ€. Additionally, there had been a number of recent admissions with posterior cerebellar infarcts to the unit over the preceding couple of weeks. This prompted the team to do a more intricate neurological examination including head thrusts and hallpikes. Of note, these were felt to be normal, but some very minor discrepancy on test of finger-nose co-ordination and heel shin testing on the right side led to the team organizing an MRI scan. This subsequently confirmed the presence of a small area of acute ischaemia on diffusion-weighted analysis in the cerebellum.
We estimate that around 6-7 cases per year with posterior circulation stroke are seen on average out of around 350 new admissions to our unit. We hope that this case highlights the point that posterior fossa stroke can present as a wide spectrum of disease and that unless clinical suspicion is raised, appropriate investigation to confirm the diagnosis may not be performed.
1: Barraclough K, Bronstein A. Diagnosis in General Practice: Vertigo; BMJ 2009;339:b3493
2: Norman G, Barraclough K, Dolovich L, Price D. Diagnosis in General Practice: Iterative Diagnosis; BMJ 2009;339:b3490
Competing interests: None declared
Patient consent obtained
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We are grateful for the helpful comments. (We should have made it clear that the approach proposed is for true vertigo in adults rather than children.)
Dr Nunez cites a study (Cnyrim et al 2008) in which 83 patients who presented to a university neurology department with acute onset of rotatory vertigo and no auditory, brainstem or cerebellar symptoms were assessed clinically with bedside tests including the ‘headthrust test’ and then also underwent caloric testing and MRI. The final diagnosis was vestibular neuritis (VN) in 40 patients. Of the other 43 patients 23 had had brainstem infarcts, 12 had brainstem demyelination and 8 had other aetiologies such as haemorrhage. 37 out of the 40 patients eventually diagnosed with vestibular neuritis had a positive (pathological) head thrust test, giving a sensitivity of 92% for the test. Rather worryingly, 17 out of 43 patients in whom the diagnosis of VN was not substantiated had a positive test, giving a specificity of only 60%. The paper does illustrate the limited performance characteristics of any single clinical test. However, in the context of primary care the incidence of significant brainstem pathology is extremely low and consequently the Positive Predictive Value of a positive (pathological) head thrust test would be orders of magnitude higher than it is in the study.
Dr Hanley points out evidence about the importance of the mechanism of vestibular compensation (and its subsequent failure) after damage to the vestibular mechanism. Dr Hanley cites evidence of the effectiveness of vestibular rehabilitation exercises something with what we couldn’t agree more. Indeed this can be successfully organised at primary care level (Yardley et al 2004). However, we are not aware that there is specific pathophysiological evidence that recurrence of true vertigo (rather than non specific dizziness or unsteadiness) can be due to vestibular decompensation after earlier vestibular damage.
Dr Symonds also identifies that patients who have previously experienced true vertigo in the past may, years later, incorrectly label a recurrence of ‘dizziness’ as vertigo when it is in fact a manifestation of anxiety. The differentiation is clinically important because the balance discomfort/ disorientation responds to psychological rather than vestibular treatment.
Reference:
Yardley L, Donovan-Hall M, Smith HE, Walsh BM, Mullee M, Bronstein AM. Effectiveness of primary care-based vestibular rehabilitation for chronic dizziness. Ann Intern Med. 2004 Oct 19;141(8):598-605.
Cnyrim CD, Newman-Toker D, Karch C, Brandt T, Strupp M. Bedside differentiation of vestibular neuritis from central "vestibular pseudoneuritis". J Neurol Neurosurg Psychiatry 2008;79(4):458-60
Competing interests: Authors of the paper
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I write in response to the excellent article on Vertigo (BMJ 2009; 339749-752)by Barraclough K and Bronstein A. Dr S.Surenthiran and I run a joint Neuro-otological/Psychiatric Balance Clinic.
I was very pleased to see the strict operational definition given to vertigo, which I regard as vital in the distinction from all the other phenomena of spatial disorientation, that occur in the patients referred to us.Perhaps the most useful contribution a psychiatrist can make in balance problems, comes from his/her rigorous training in phenomenology, the description of the patient's experience in the patient's own terms, value-free and without theoretical pre-conceptions; harder than one might think. Patients come to us using language they think we might appreciate, and 'vertigo' predominates. Identifying the presenting balance symptom as (true) vertigo, locates the cause in the semicircular canals, and rarely brain-stem. These comprise the minority of patients I see, who, by contrast, describe with difficulty, a range of discomfort/disorientation phenomena, that demand differential diagnosis.
One disease pattern is common and has been described elsewhere: a patient develops typical Benign Positional Vertigo, from which they recover uneventfully. Years later they suddenly develop 'dizziness' which they represent as vertigo. In fact it is usually the onset of an anxiety state, (Generalised Anxiety Disorder) for a variety of reasons, in which balance discomfort predominates. A simple conditioning model may be used in explanation, with vertigo as the unconditioned stimulus: or, a cognitive model in which sudden fundamental threat is interpreted through the previous experience of vertigo, but of course without the vestibular system pathology to produce it. The treatment is Cognitive-Behavioural and central to this is the patient being able to discriminate between vertigo and their version of 'dizziness'.
Yours sincerely
R.L.Symonds
Competing interests: None declared
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Dear Sir,
The excellent article in your series “Diagnosis in General Practice†entitled vertigo demonstrates the use of iterative diagnosis in this relatively common symptom in the community1. As stated in the accompanying article2 the initial hypothesis uses a limited list of possible diagnoses which are then tested by gathering further data in the consultation. This process has fascinated me, in particular when presented with the symptoms of vertigo, since I became interested and conducted some research on the topic a number of years ago3 4. I have continued to explore the patterns underlying presentations of vertigo in general practice and have come to the conclusion that there has been a thorough under-appreciation of the common condition of vestibular decompensation. Professor Linda Luxon, in particular, has frequently described this condition, it’s pathophysiology, the clinical features, and how to manage it5-7. Stated simply, damage to one or other of the vestibular organs occurs some time prior to presentation and the patient symptomatically recovers. Lost hair cells within a vestibular sensory receptor do not regenerate6. The damage done to the vestibular nerve in acute vestibular neuritis, does not always recover, similar to persisting Bell’s palsy. A compensation process is achieved by recalibration of the gain in the vestibular reflexes and reinterpretation of the sensory inputs in the balance centres in the brainstem and cerebellar and cerebral cortices7. This recovery counteracts a persisting minor mismatch in the signal from the affected vestibular body when compared to the other side. Characteristically there is onset of vertigo when the person is tired or stressed or when the visual or proprioceptive inputs to the vestibular system are confused by flashing lights or walking over rough ground such that the compensation system temporarily fails.
The value to the patient of vestibular rehabilitation exercises have been confirmed in general practice8 9 but strangely the concept of vestibular decompensation has not yet entered the working list of the initial hypothesis of the GP when faced with a presentation of vertigo. In a series of thirty one patients who have been referred to me by colleagues in the last five years, 13 (54.5%) had a recognisable pattern of vestibular decompensation. Five of these had an identifiable initial vestibular insult some years before; acute vestibular neuritis in four and a chronic suppurative otitis media in one. In my own clinical practice, two patients have presented to me with a pattern of vestibular decompensation out of twenty two who presented with vertigo in the last three years; the remainder of the pattern being similar to previously described. Authors continue to despair at the perceived association between persistent vestibular symptoms and psychological issues10, but where the symptom is true vertigo I believe we do our patients a disservice. I believe the condition of vestibular decompensation should be added to the working diagnostic list of the GP. This list should be ? benign positional vertigo/acute vestibular neuritis/vestibular decompensation/Meniere’s disease/something more serious. When those patients suffering from vestibular decompensation are recognised, counselled and if necessary offered vestibular rehabilitation the management of vertigo in general practice will become much more satisfactory to our patients and to ourselves.
1. Barraclough K B. Vertigo. BMJ 2009;339:749=752.
2. Norman G. Iterative Diagnosis. BMJ 2009;339:747-8.
3. Hanley K, Dowd TO. Symptoms of vertigo in general practice: a prospective study of diagnosis. British Journal of General Practice 2002;52:809-812.
4. Hanley K, Dowd TO, Considine N. A systematic review of vertigo in primary care. British Journal of General Practice 2001;51:666-671.
5. Luxon L. Vertigo: new approaches to diagnosis and management. Br J Hosp Med 1996;56:519-20, 537-41.
6. Luxon L, Davies R. Handbook of Vestibular Rehabilitation. London: Whurr Publishers Ltd, 2000.
7. Luxon LM. Evaluation and management of the dizzy patient. J Neurol Neurosurg Psychiatry 2004;74:iv45-iv52.
8. Yardley L, Beech S, Zander L. A randomised controlled trial of exercise therapy for dizziness and vertigo in primary care. BR J Gen Pract 1998;48:1146-40.
9. Yardley L, Luxon L. Treating dizziness with vestibular rehabilitation. BMJ 1994;308:1252-3.
10. Best C, Eckhardt-Henn A, R T. Why do subjective vertigo and dizziness persist over one year after a vestibular vertigo syndrome? Annals of the New York Academy of Sciences 2009;1164:334-7.
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Dear Sir or Madam:
I congratulate Barraclough & Bronstein1 on their succinct article on vertigo diagnosis. My experience performing the Dix-Hallpike test supports the recommendation that it can be performed satisfactorily without placing the patient with their neck extended (hanging off the couch). It is important for readers to be aware that it is presumptuous to make a diagnosis of Meniere's Disease on the basis of a single episode of vertigo even if accompanied by features of hearing loss, tinnitus and aural pressure. The American Academy of Otolaryngology committee on Hearing and Equilibrium guidelines on Meniere’s disease diagnosis recommends that the diagnosis is not made unless there is more than one attack2. The Halmagyi head thrust test is useful in distinguishing labyrinthine vestibular failure from central vestibular disorders however it is an oversimplification to imply that this test has 100% sensitivity3.
Desmond A Nunez Consultant/Honorary Reader in Otolaryngology
1. Barraclough K, Bronstein A. Vertigo. Bmj 2009;339:b3493.
2. Committee on Hearing and Equilibrium guidelines for the diagnosis and evaluation of therapy in Meniere's disease.American Academy of Otolaryngology-Head and Neck Foundation, Inc. Otolaryngol Head Neck Surg 1995;113(3):181-5.
3. Cnyrim CD, Newman-Toker D, Karch C, Brandt T, Strupp M. Bedside differentiation of vestibular neuritis from central "vestibular pseudoneuritis". J Neurol Neurosurg Psychiatry 2008;79(4):458-60.
Competing interests: None declared
Competing interests:
I would like to congratulate Kevin Barraclough and Adolfo Bronstein on their excellent coverage of vertigo as a presenting symptom to a general practitioner. The article was lucid and practical and contained the evidence that will enable early accurate diagnosis of what can be a most disturbing symptom. It would have been nice to see a little more about management strategies that could be instituted in a GPs surgery, but perhaps I am pre-empting the next paper from Prof. Bronstein. I would, however, like to point out that this article only applies to adult patients. Children complaining of unsteadiness, dizziness or vertigo present with entirely different pathologies.
For example, benign paroxysmal positional vertigo (BPPV), which is common in adults, is very rarely seen in children and then only with a history of preceding head trauma of some significance, while migrainous vertigo and its equivalent, benign paroxysmal vertigo of childhood (BPVC) (not to be confused with BPPV), are relatively common causes of recurrent vertigo. On the other hand, a history of recent unsteadiness in a child may herald an intracranial tumour, while child abuse and visual difficulties can both present as dizziness. The diagnostic list for children is no less exhaustive than for adults, but it is different.
Furthermore, obtaining a relevant history from a child and performing a neuro-otological assessment in order to differentiate one cause from another requires not inconsiderable expertise.
The child’s presentation and the diagnostic pathway for dizziness in children are different from adults. Therefore, while I applaud the excellent diagnostic pathway outlined in this paper, I would ask that it be made very clear that it is for adults only
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We enjoyed reading the article entitled: Diagnosis in General Practice: Vertigo, by Kevin Barraclough, general practitioner1, Adolfo Bronstein, professor of neuro-otology.
In our acute trust, we spend so much time adhering to the "bare below the elbows" policy that we were suprised to see a photograph of a patient being examined by a doctor wearing a watch, long-sleeved shirt and tie!
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Re: Vertigo
In the responses a case is described of a lady admitted via ED with vertigo. Her head impulse test is normal. This is ABNORMAL and demonstrates the importance of the head impulse test.
An abnormal head impulse test is indicative of vestibular pathology, therefore a NORMAL head impulse test is ABNORMAL in a patient with vertigo. It suggests a brainstem or cerebellar cause of vertigo.
The HINTS test looks to demonstrate this further with the addition of the assessment of nystagmus (bi directional or vertical suggesting a central lesion) and the test of skew. Here vertical correction again is abnormal.
If any three of these things are abnormal the patient requires an MRI and stroke opinion.
Of note in this case, the patient couldn't walk which is always worrying. Peripheral vertigo is horrible but you can generally still walk. She also had risk factors which should prompt you to ensure someone confident in assessment is involved.
Competing interests: No competing interests