I’m giving the talk on vertigo at the EMCORE, however several people have asked, after reading the blog on the HINTS study, for a quick summary of my approach to the patient with dizziness. Here is a very, very quick summary in the form of a 4 minute video. More detail at the conference. My approach is straightforward:
History
I’m interested in the patient’s history. If they are elderly, have had a history of TIA or stroke or are in atrial fibrillation, I worry.
I’m interested in the history of the event. The aim here, is to rule out other causes of lightheadedness, or dizziness, including cardiac causes such as arrhythmias. If this is episodic vertigo that occurs only when the patient moves their head and there are no other symptoms, I worry less, as isolated vertigo is rarely central.
Examination
Upper limb and lower limb neuro, especially looking at long tract signs.
Walk them– gait is important. A patient with a peripheral cause of vertigo, may be very dizzy, but will still be able to walk. Someone with a central cause, will not be able to walk and will fall back into the bed. I look also for truncal ataxia.
Talk them – Ensure no speech disturbances
Look into their eyes – The eye examination is probably associated with a higher yield in this group of patients.
I look for diplopia firstly, then for nystagmus(vertical, bidirectional,rotational suggests a central cause), then perform the head impulse test(a normal test indicates a central cause) and test for skew(vertical skew indicates a central cause). Some of these eye signs have been associated with a sensitivity equal to early MRI.
Details and videos of this at the EMCORE.
