77-year-old female with a PMH including TIA and hydrocephalus s/p VA shunt.
Presents with episodic “room-spinning” dizziness for one week.
Episodes are sudden-onset, last one minute, and are precipitated by certain head movements, such as looking upward or turning over in bed.
ROS is negative for numbness, weakness, trouble with speech, hearing loss, and tinnitus.
On physical exam, Dix-Hallpike maneuver was significant for bilateral rightward horizontal nystagmus. Patient demonstrated steady gait with ambulation in the ED.
CT head non-contrast and shunt series were both unremarkable.
Pt improved in ED with Epley maneuver and one dose of meclizine 25 mg PO prior to being discharged home.
In a patient who presents to the emergency department with symptoms of vertigo, what bedside tools can be used to help differentiate benign paroxysmal positional vertigo (BPPV) from the more serious central etiologies of vertigo, such as stroke?
Summary of Evidence: It has been estimated that there are approximately 2.6 million ED visits annually for the evaluation of dizziness.1 While there are less serious peripheral causes of dizziness, such as BPPV, there are also more emergent, central causes of dizziness, such as stroke, that must be considered.
Doijiri et. al. performed a retrospective analysis of 221 patients (119 men; 102 women) with a mean age of 68.4. Over a ten-year span, these patients were admitted for sudden isolated vertigo or dizziness without other neurologic symptoms except for nystagmus, deafness, or tinnitus. Neuroimaging showed that 25 of these patients (11.3%) had recent stroke lesions. Of the 25 lesions, the majority of them were located in the cerebellum (n=21).2 This supports existing data that cerebellar strokes may be a missed diagnosis in patients who appear to have peripheral etiologies of vertigo, which carries an increased morbidity and mortality risk.3,4 Furthermore, these findings demonstrate the importance of working up dizziness with beside exams and pursuing further imaging when indicated.
The Dix-Hallpike test has historically been used in the diagnosis of BPPV, and has a sensitivity of 79% and specificity of 75%. Additionally, the Side-lying test is a modification for those unable to move into the Dix-Hallpike position and has an estimated sensitivity of 90% and specificity of 75%.5 Of note, simply repeating the Dix-Hallpike and Side-lying maneuvers can help increase sensitivity and specificity. In a study of 207 dizzy patients, 139 participants were diagnosed with BPPV after the first maneuver of either the Dix-Hallpike or Side-lying tests. With a subsequent trial of the maneuver, an additional 28 patients were diagnosed with BPPV.6
For a video demonstrating the Dix-Hallpike test, please visit: https://www.youtube.com/watch?v=8RYB2QlO1N4
For a video demonstrating the Side-lying maneuver, please visit: https://www.youtube.com/watch?v=Awd-P0Or_uk
A more recent development in the evaluation of patients presenting with dizziness or vertigo is the HINTS (Head Impulse, Nystagmus, and Test of Skew) exam, a three-part bedside clinical tool. The HINTS exam has been shown to have greater sensitivity in ruling out stroke than neuroimaging studies, such as MRI, when obtained in the first two days of symptom onset.7 This exam can be applied to symptomatic patients only, and variation in provider skill in performing the maneuvers can potentially limit the accuracy of the HINTS exam.
Head Impulse: To perform this portion of the exam, have the patient fix their gaze on your nose. You will move the patient’s head to the left and right, while asking the patient’s eyes to remain fixed on your nose. If the vestibular system is affected, as would be seen in vertigo, the eyes will make a corrective saccade movement before re-fixating on your nose. If the vestibular system is functioning normally, the eyes will remain fixated.
Nystagmus: In patients with vertigo, expect to see either no nystagmus or horizontal nystagmus. Any other type of nystagmus, such as torsional (rotary) nystagmus, is considered abnormal.
Test of Skew: Again, have the patient focus on your nose. You, the examiner, will cover one of the patient’s eyes then quickly uncover the eye. Look for any eye movement. Observation of eye deviation points toward brainstem involvement. In patients with peripheral vertigo, there should be no ocular deviation.
If any of the three components of the HINTS exam are abnormal, consider central causes of vertigo, and obtain neuroimaging and/or neurologic consultation.
For a video demonstrating the HINTS exam, please visit: http://www.kaltura.com/index.php/extwidget/preview/partner_id/797802/uiconf_id/27472092/entry_id/0_b9t6s0wh/embed/auto
Recommendations: When caring for a patient in the ED who presents with vertigo, one should not only consider peripheral causes, but also give thought to central etiologies, such as stroke. The Dix-Hallpike and Side-lying tests are excellent starting points for the physical exam. Additionally, providers should become well-acquainted with the HINTS exam and use this three-step bedside tool for assessing symptomatic patients. With practice, this exam can be performed very quickly, and can provide meaningful information when moving forward with the clinical assessment and management of patients experiencing dizziness.
Newman-Toker DE, Hsieh YH, Camargo CA Jr, Pelletier AJ, Butchy GT, Edlow JA. Spectrum of dizziness visits to US emergency departments: cross-sectional analysis from a nationally representative sample. Mayo Clin Proc. 2008;83(7):765–775. doi:10.4065/83.7.765
How Commonly Is Stroke Found in Patients with Isolated Vertigo or Dizziness Attack? Doijiri, Ryosuke et al. Journal of Stroke and Cerebrovascular Diseases, Volume 25, Issue 10, 2549 – 2552
Berry, Diane C., et al. "Cerebellar Stroke: A Missed Diagnosis." Advanced emergency nursing journal 39.3 (2017): 184-192.
Nelson, James A., and Erik Viirre. "The clinical differentiation of cerebellar infarction from common vertigo syndromes." Western Journal of Emergency Medicine 10.4 (2009): 273.
Halker, Rashmi B., et al. "Establishing a diagnosis of benign paroxysmal positional vertigo through the dix-hallpike and side-lying maneuvers: a critically appraised topic." The neurologist 14.3 (2008): 201-204.
Evren, Cenk, et al. "Diagnostic value of repeated Dix-Hallpike and roll maneuvers in benign paroxysmal positional vertigo." Brazilian journal of otorhinolaryngology 83.3 (2017): 243-248.
Quimby AE, Kwok ESH, Lelli D, Johns P, Tse D. Usage of the HINTS exam and neuroimaging in the assessment of peripheral vertigo in the emergency department. J Otolaryngol Head Neck Surg. 2018;47(1):54. Published 2018 Sep 10. doi:10.1186/s40463-018-0305-8