Disclosure• Nothing to disclose

Outline• Epidemiology of dizziness and stroke• History and Exam of dizzy patient• Differentiating peripheral vs central• Migraine associated dizziness• Chiari

Bottom Line

CM Fisher’s 6 weeks-months rule

Isolated DizzinessAssociated Symptoms• Nausea• Vomiting• Blurred Vision• Unsteadiness• Fatigue• “Disorientation”/ “confusion”

How common is it that patients with TIA/Stroke present with dizziness?• 3.2% of “dizzy” (any type) patients in ER have TIA/stroke• ~1 % of all patients with isolated dizziness have TIA/stroke

(translates into large #)• 17% of TIA/stroke present with isolated dizziness

Kerber. Stroke 2006; 37: 2484-7*Newman-Toker. Neurology 2008; 70:2378-85

TIA/Stroke Missed

Kerber. Stroke 2006; 37: 2484-7

Physicians do not make TIA/stroke diagnosis in 35% of dizzy patients

Reasons for Misdiagnosis-History

• Too much emphasis on type:• in survey of doctors:

• 93% said type of dizziness is very important

• This is NOT true:• Vertigo vs Dizziness: equal odd for stroke*• Vertigo can be non-vestibular

• “cardiogenic (8% of MI)**• orthostatic (37%)**

Lewandowski. Ann Emerg Med. 2008; 52(2):S7-16 *Kerber. Stroke 2006; 37: 2484-7**Newman-Toker. Nat Clin Practice 2006;2:167-72

Reasons for Misdiagnosis-History

Moreover, patients often cannot describe symptoms

Patients change their description >50% of time depending on how we ask the question!

Do NOT waste time on TYPE.

Newman-Toker. Mayo Cli Proc 2007; 82(11):1329-40Caplan. Mayo Clin Proc 2007; 82:1313-5Stanton. Mayo Clini Proc, 2007; 82:1319-28Kerber. Stroke 2006; 37: 2484-7Newman-Toker. Nat Clin Practice 2006;2:167-72

Reasons for Misdiagnosis-History• Not enough emphasis on duration• Only 13% asked about duration• Yet duration is MORE important than type

• Seconds: BPPV• Minutes: TIA• Hours: Meniere• Day or days: acute peripheral vestibulopathy (“labyrinthitis”) or

Stroke or Migraine• Note: migraine can be seconds to constant; mostly though less

than one day

Caplan. Mayo Clin Proc 2007; 82:1313-5Stanton. Mayo Clini Proc, 2007; 82:1319-28Kerber. Stroke 2006; 37:2484-7

Reasons for Misdiagnosis-History• Onset:

• Hyperacute/sudden: central• Over minutes/hours: peripheral

• If recurrent, when was initial onset• 6 weeks rule (Fisher CM. Arch Otolaryngol 1967; 85:529-34)

• Exceptions:• Weeks-months (Inui. Acta otolaryngol 1998;533:46-50; Oas & Baloh.

Neurology 1992;42:2274-9)• Cases 1-2 yr (Kerber. Neurol 2005;65;962)• One up to 4 yrs (Gomez, Neurol 1996)

• Modified Rule is 6 months rule

Reasons for misdiagnosis-Imaging

• Dizziness in ER between 1995-2004*• Utilization of imaging increased 169% yet rate of diagnosing a

central cause did not increase• There is unduly reliance on CT in ER!

• In 200 patients, yield was ZERO**• Total cost $ 60,000

• Posterior circulation MRI-DWI can be negative in first day• 10%*** or 30%¶

*Kerber Aca Emerg Med 2008 Jul 14**Emerg Med J 2005; 22:312¶Oppenheim AJNR 2000; 21;1434-40***Newman-Toker. Neurology 2008; 70:2378-85

MRI-DWI is falsely negative in up to 30% in posterior circulation stroke infirst 24 hrs

Oppenheim AJNR 2000; 21;1434-40

Falsely Negative MRI

To Improve Diagnosis: Dizzy History• Onset: hyperacute (central) or minutes-hours• If Recurrent: initial onset < 6 months (worry!)• Is Balance Problem severe/crawled (central)• Hearing (peripheral or central)• Headache (occipital)/neck (central)• Associated Neurological symptoms (central)

• Dysarthria• Dysmetria (clumsiness: dialing phone)• Diplopia• Dysphagia• Hiccups• Numbness/weakness

To Improve Diagnosis: Dizzy Exam• Hearing• Head Impulse• Skew Deviation/head Tilt (ocular tilt reaction)• Nystagmus• Past pointing• Oculomotor: saccades, pursuit, OKN• Romberg : < or > 3 seconds• Fukuda• SVV

Exam-Nystagmus• Peripheral

• Lasts 1-2 days (so chronic nystagmus is CENTRAL) • Unidirectional• Horizontal/torsional• Suppressed by fixation- penlight-cover test• Contralateral to bad ear

• Central• Gaze evoked• Vertical: down or up

• If new onset nystagmus: patient in distress

Copyright ©2009 BMJ Publishing Group Ltd. Newman-Toker, D E et al. J Neurol Neurosurg Psychiatry 2009;80:900-903

Exam-Nystagmus

Red flags on history and exam that point to central• Hyper acute onset• Nystagmus that changes direction (gaze evoked) or vertical (down

or upbeating)• Abnormal pursuit/saccades/OKN• Presence of Skew• Absence of head impulse• Moderate to severe abnormal Romberg/Crawl• Imbalance out of proportion to dizziness (or imbalance without

dizziness)• Occipital Headache/neck pain

TRIAD BETTER than MRI within first 24 hours!

Edlow et al. Lancet 2008; 7:951-64Kattah. Stroke 2009; 40:3504-10

Triad:Head Impulse

NystagmusSkew

Sensitivity Specificity

Head impulse: abnlUnidirectional Nystagmus

Skew: absent

Includes 78% of acute

peripheral vestibulopathy

Excludes 91% of stroke

Head impulse: nlGaze Evoked Nystagmus

Skew: present

100% for stroke

96% for stroke

Migraine Associated Dizziness• Underreported• Many names:

• Vestibular migraine, migrainous vertigo, migraine associated vertigo, migraine related vestibulopathy

• 25-50+ % of migraineurs have dizziness (Bayazit 01; Kayan 1984)• Any type

• Vertigo• Lightheadedness• Space and Motion intolerance

• Any duration (seconds to days)- Furman 03• Seconds ~ 20%• Minutes ~30%• Hours ~30%• Days ~ 20-40%

Bisdorff. Ther Adv Neurol Disord 2011Baier, Dieterich. J Neurol 2009Furman. Curr Opin Neurol. 2003Bayazit. Rev Laryngol otol Rhinol 2001Kayan. Brain 1984

Migraine Associated Dizziness• Car sickness in patient and/or family• Auditory 40% (fullness, transient hearing loss, tinnitus)-Baier

09• Most of time, dizziness has no relationship to headaches.• Age late 30s to early 40s (Furman 03)• Headaches predate by 8.4 y (Furman 03)• Anxiety (MARD)- Furman 2005

• 60% anxiety and 16% panic• May be via serotonergic pathways

Baier, Dieterich. J Neurol 2009Furman. J Neuro Neurosx Psych 2005Furman. Curr Opin Neurol. 2003

Migraine associated dizziness• Pathophysiology unknown• On ENG: both central and peripheral abnormalities• Central:

• Vestibular nuclei connections with dorsal raphe nucleus and nucleus raphe magnus (serotonin)

• Vestibular connections with locus coeruleus (norepinephrine)• Vestibular connections with trigeminal nucleus caudalis• All above nuclei/systems implicated in migraine

• Peripheral:• prominent trigeminal sensory innervation of stria vascularis,

spiral modiolar blood vessels, dark cell region of cristae ampularis.

• Calcitonin gene-related peptide expressed by efferents to both cochlear and vestibular epithelia

Furman. Curr Opin Neurol 2003

MAD-Diagnosis• Definite (Neuhauser 2001)

• 1-vestibular sxp, at least moderate (such as vertigo, positional vertigo, motion intolerance) (Furman 03: not only dizziness)

• 2-IHS- migraine in past or present• 3-at least one (with ≥ 2 spells)

• Migraine, photophobia, phonophobia, visual or other aura• No other cause

• Probable: HIS or #3 or ≥ 50% improvement with migraine meds or ≥ 50% ppt with migraine triggers (sleep, food, hormones); and other causes ruled out.

• Exam/ENG/posturography: 50+ % abnl: vestibular pattern on posturography; caloric abnl in ¼; DP; position related nystagmus, central findings)*

Neuhauser. Neurol 2001* review see Furman. Curr Opin Neurol 2003

Migraine associated dizziness• DDX: meniere, TIA, vestibular spells from MS/seizures• Workup:

• ENG• Audiogram• Brain MRI• Vascular imaging• EEG

• Potential link between migraine and meniere• Meniere pts have increased prevalence of migraine• 45% of meniere pts have at least one migrainous sxp during the

vertiginous attacks• 26% of meniere pts failed to respond to treatment and

subsequently respond to migraine treatment• BUT: need more studies and use of common criteria for dx.

Baier, Dieterich. J Neurol 2009Furman. Curr Opin Neurol. 2003

Migraine Associated DizzinessTreatment• All studies small• Nonpharmacological: diet, sleep, exercise, avoid triggers• Preventive: TCA, propranolol, SSRI, Clonazepam, antiepileptic

such as Topiramate 100, valproic acid 500; note Lamotrigine 100 if dizziness is prominent and headache is not

• Calcium channel blockers ineffective in some studies• Abortive: NSAID, meclizine, promethazine 25-50, sumatriptan

(one study); rizatriptan: possible; zolmitriptan: inconclusive• Avoid ergots• Consider furosemide, flunarizine, keppra (aura/headache)• Familial: acetazolamide• Vestibular rehab: deconditioned, visual dependence• Overall Rx success 80% (+/-); usually not cure but help.

Bisdorff. Ther Adv Neurol Disord 2011

Chiari and Neurotology• Headaches Occipital 36%• Headache Generalized 29%• Dizziness 32%• Vertigo 21%• Lightheadedness 9%• Tinnitus 27%• Sensory deficit in UE 30%• Vision changes 25%• Weakness 23%

• Neurological exam abnormal in about 50%• Horizontal nystagmus 30%• Vertical nystagmus (down > up) 19%

Kumar. Otology & Neurotology 2002

BPPV (on RIGHT)

Nystagmus looking to left:Upbeat to forehead

Nystagmus looking to right:Torsional to floor

But if vertical (downbeat) then central

Summary• Do not worry about type of dizziness• Ask about duration (minutes-worry about TIA) • Ask about onset (hyper acute or not)• Worry if + occipital headache/neck pain/neuro sxp• If recurrent, check initial onset- 6 months rule• Do Neuro-otology exam• If unidirectional nystagmus but negative head impulse: central • If + impulse but + skew: central

Summary• Peripheral Nystagmus lasts 1-2 days• Chronic nystagmus (ie nystagmus in a patient NOT in acute

distress) is central• Labyrinthitis does not recur (very rarely)• Do not let MRI give you false confidence• Worry about the elderly with stroke risks but do not forget the

young

Summary• Obtain an MRI if patient has ONE of:

• Negative Head Impulse• Gaze evoked Nystagmus• Vertical Saccadic Pursuit• Skew Deviation• Multiple stroke risk factors

• Also if:• Hyper acute onset (seconds)• Very severe imbalance (crawled)• Headache, especially occipital or cervical

Kattah. Stroke 2009; 40: published ahead of print Cnyrim (Brandt). J Neurol neurosurg Psych 2008;79:458-60Newman-Toker. Neurology 2008; 70:2378-85Kim. J Neurol Sci 2007; 254:99-101

THANK YOU