Vertigo Exam:
-
Detailed cranial nerve exam (r/o brainstem stroke) – nystagmus is key!!
Remember vertical and pure rotatory nystagmus are generally central
Check for vertical skew deviation – c/w central cause
Orthostatics (r/o other causes of dizziness)
Dix-Hallpike, consider performing Epley
“Ophthalmoscope Frenzel Lenses” - patient covers eye, and look at fundus for nystagmus. Remember retinal vessels go in opposite direction eye movement!
Weber/Rinne if hearing loss present
-
3Ds of dizziness to ask about: Dysarthria, Diplopia, Dysphagia
Dysarthria - PaTaCa or MaLaGa tests labial->lingual->palatal
Diplopia - monoc/binoc, how many, horiz / vert
Dysphagia - coughing, trouble swallowing esp liquids
-
HINTS test - Head Impulse / Nystagmus / Test of (vertical) Skew
HI: head turned in towards side of vestibular dysfxn -> delayed corrective saccade opposite; normal HI is worrying for central
N: direction changing / vertical / dominant torsional all worrying for central; only horizontal unidirectional following Alexander’s Law with fast phase increasing with gaze away from side of vestib dysfxn is supportive of peripheral
TS: cover/uncover with vertical correction concerning for central
INFARCT acronym for central signs - Impulse Normal, Fast-phase Alternating vertical/torsional, Refixation on Cover Test
When concerning findings present: 100% sensitive, 96% specific
-
CAUTIONS:
Auditory loss not reassuring (AICA -> labyrinthine / cochlear infarct)
Craniocervical pain more freq in central (38% vs 12%)
Prominent rotary or vertical nystagmus always bad outside of dix-hallpike
Severe truncal ataxia (inability to sit unpropped) only in central. In 36% of pt w/ lat brainstem or cerebellar strokes this was only sign
If pt truly cannot walk, unlikely to be peripheral
Diplopia rarely reported even with skew