Dizziness and Vertigo By The Doctors Of Emergency Medicine Cases #6

In Episode #6 July 2010 [link is to the show notes and the podcast] of Emergency Medicine Cases, Dr. Anton Helman leads the discussion with Drs. Himmel (emergency medicine) and Selchen (neurology).

The podcast has three parts:

  1. Transient Ischemic Attack from time 0 to
  2. Brief discussion on atrial fibrillation and hypertension from 83:00 to
  3. Dizziness and vertigo from 134:00:00 to

This post is about the third part of the podcast whereDrs. Hellman, Himmel, and  discusses dizziness and vertigo brilliantly teach us about the evaluation in Emergency Medicine Cases #6The show notes and podcast are simply outstanding so just go there and read again and again! And listen to the entire podcast at least a couple of times.

Dr. Himmel begins by reminding us that there are four kinds of strokes and TIAs, four kinds of investigations, four kinds of dizziness, and four kinds of vertigo:

4 types of stroke and TIA and 4 types of appropiate investigations

Types of Stroke TIA and Appropriate Investigations

  1. Cardioembolic (1/4 of TIAs) ECG: Look for a.fib (12‐16% of stroke) and other cardiac problems that might cause embolic phenomena from the heart: CHF, recent MI, left ventricular aneurysm, rheumatoid heart disease, valvular disease); if the ECG looks like acute MI and a severe headache ispresent, think of ICH and SAH. [An echocardiogram is also indicated looking for LV dysfunction, RV dysfunction or pulmonary hypertension, silent valvular disease and left atrial enlargement (which can suggest the presence of intermitent or prolonged or persistent atrial fibrillation)]
  2. Lacunar TIAs (1/4 of TIAs)
    Classically: pure motor and pure sensory, or mixed‐motor‐sensory but without cortical findings (below)
    Unenhanced CT head: To rule out TIA mimics (tumor, SDH, ICH, SAH – especially given that ASA will be given), and see old strokes
  3. Large arteries in neck, brain (1/4 of TIAs)
    Cortical findings: aphasia (sometimes mistaken for confusion) means left hemispheric involvement; neglect means right‐hemispheric involvement; visual disturbances (field cuts) Vascular imaging: Organize for carotid Doppler in the neck 1‐3d maximum, or consider adding CT‐angiogram to CT head (which can assess for intracranial arteries) [also when you are worried about the possibility of posterior circulation involvement, get a diffusion weighted MRI to look for previous silent posterior circulation stroke, Dr. Selchen advises.– see discussion below
  4. Other TIAs (1/4 of TIAs)
    Intracranial hemorrhages (15%), cryptogenic, clotting diosrders, PFOs
    Blood: Accucheck and blood work (CBC, lytes and blood sugar, BUN, Cr, INR) and

And other important causes of TIA: Carotid dissection: young patient with no risk factors, especially if associated with trauma or sudden, rapid movement of the neck, neck pain (anterior pain in carotid dissection, posterior pain in vertebral dissection), vertigo or headacheEndocarditis: unwell for weeks, flu‐like symptoms, recurring fever, weight loss, and headache

4 types of dizziness (there’s always one that predominates):

  1. Syncope / pre‐syncope: feeling of passing out
  2. Vertigo: hallucination of rotation or linear movement; spinning
  3. Disequilibrium: cannot walk properly, staggering
  4. Non‐specific light‐headedness

4 types of vertigo (based on duration of symptoms):

  1. Less than 60sec: Positional event (MARKEDLY worse with movement)
  2. Minutes (few to 30): If not positional: migraine (in young, low‐risk patients) or TIA/CVA (in older, at‐risk patients)
  3. Many hours: Vestibulopathy, Ménière’s disease
  4. Days: Labyrinthitis, or stroke

Approach to vertigo

The easiest way to rule out an ominous central cause is by ruling in a benign peripheral cause:

  1. BPPV: <1min, normal in between attacks, Dix‐Hallpike positive (see below), Epley maneuver cures it in 50% of cases (see youtube)
  2. Vestibular neuronitis: acute severe constant vertigo, positive head‐thrust manoeuvre (see below)
  3. Ménière’s disease: >20mins to hrs in combination with tinnitus, ear fullness or decreased hearing

Vertigo History

Features suggestive of posterior circulation ischemia: diplopia, ataxia (especially between episodes), dysarthria (slurred speech) and dysphagia – and central cause: non‐positional or bidirectional nystagmus, inability to ambulate, focal neurological deficit and cerebrovascular risk factors

Note: all causes of vertigo can be worsened by head movement

Vertigo Physical examination

  • Unidirectional horizontal nystagmus is usually peripheral in nature, whereas vertical, pure torsional and/or bidirectional nystagmus, limb ataxia and pinprick sensation asymmetry are usually central

Dix Hallpike test:

  • Useful in ruling in BPPV only if CLASSIC response: brief latency of 3‐5 seconds, dramatic response with vertical or rotatory eye movements that stop after 30‐60sec, and fatigability if the test is repeated

Head thrust test:

  • Abnormal test (unilateral latency in eye repositioning when the head is thrust) is indicative of peripheral lesion (eg, vestibular neuronitis with acute, severe and constant vertigo) almost always.

See also Resources at the bottom of the post.

One of the tests of posterior circulation dysfunction (specifically cerebellar involvement) is limb ataxia. So Dr. Selchen says that he always tests for limb ataxia which means testing finger to nose to finger in both upper extremities and testing each lower extremity for knee to heel to shin. See YouTube video Limb Ataxia from NIH Stroke Scale Instruction for a how to.

Cerebellar signs (including abnormal eye movements, intention tremor, dysmetria, dysdiadokinesis as well as the characteristic abnormal gait) are all demonstrated in the six minute YouTube video titled 2. Cerebellar Gait Ataxia – Video Library of Gait Disorders. This video is simply awesome. Watch it over and over.


ABCD2 score: Combination of California Score and ABCD Score, and most relevant to Emergency Physicians because of 2‐day risk of stroke (as opposed to 90 days or 7 days for the others)

Points Criteria
1 Age > 60
1 Blood pressure > 140 systolic or > 90 diastolic
2 Clinical feature: Unilateral weakness
1 Clinical feature: Speech disturbance
2 Duration of symptoms: > 60min
1 Duration of symptoms: 10-60 min
0 Duration of symptoms: < 10 min
1 Diabetes
Score interpretation:

Score 0‐3 = low risk (1% risk of stroke at 48hrs)
Score 4‐5 = moderate risk (4% at 48hrs)
Score 6‐7 = high risk (8% at 48hrs)

Diagnosis of Transient Ischemic Attack (TIA) Using the ABCD2 Score from the Ischemic Stroke Module of the Emergency Neurological Life Support Course [To Determine the Urgency of the Evaluation]
Posted on September 11, 2015 by Tom Wade MD

 Attacks PDF

Links to 2014 Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack + Other Resources blog post of January 30, 2016 at tomwademd.net.

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