今日の臨床サポート

めまい

著者: 林理生 社会医療法人友愛会 恵愛病院 内科

監修: 野口善令 豊田地域医療センター 総合診療科

著者校正済:2022/04/27
現在監修レビュー中
参考ガイドライン:
  1. 米国耳鼻咽喉科・頭頸部外科学会(AAO-HNSF):Benign Paroxysmal Positional Vertigo (BPPV) - Update March 2017
患者向け説明資料

概要・推奨   

  1. 「めまい」の分類には、めまいの性状ではなく病歴を重要視することが強く推奨される(推奨度1)
  1. 良性発作性頭位めまい症 (BPPV:benign paroxysmal positional vertigo) におけるDix-Hallpikeテストの感度は50~78%程度であるが、Dix-Hallpikeテスト陽性で嘔吐または回転性めまいがある場合はBPPVの可能性が高くなる(陽性尤度比7.6)ため、末梢性めまいを疑う場合には行うことが推奨される(推奨度2)
  1. 神経局在所見を認めにくい脳血管障害によるめまいは、前下小脳動脈領域の閉塞で生じやすい。見逃さないためには、持続時間が長い回転性めまいにおいて聴力障害・歩行障害の確認、血管障害の危険因子の確認が重要である(推奨度1)
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
林理生 : 特に申告事項無し[2022年]
監修:野口善令 : 特に申告事項無し[2022年]

改訂のポイント:
  1. 定期レビューを行い、問診・診察のポイント、画像検査の項の加筆修正を行った。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. めまいとは、主観的な感覚であり、ときに言語化が難しいが、目が回るような感覚、浮遊感、目の前が暗くなることなどを表すことが多い。
  1. めまいを訴える患者の50%程度は末梢性めまい。中枢性めまいは10%程度、前失神は10%程度、その他の原因および原因不明が30%程度である。
  1. 中枢性めまいや前失神を見落とすと、その後の死亡リスクが高くなる。これらの危険なめまいを見逃さない。
問診・診察のポイント  
めまいの初期診療の目標は、確定診断をつけることよりも、後方循環系脳卒中や他の危険な原因疾患から良性末梢性前庭障害を区別することである[1]
 
  1. めまい(dizziness)を回転性めまい(vertigo)、前失神(presyncope)、不安定性めまい(平衡障害:disequilibrium)とふらつき(light-headednessを含むnonspecific dizziness)の4つに分類して診断を進める方法が普及してきたが、その方法では「めまい」の性状は再現性に乏しく、正しく診断できない危険が高いことが近年報告されている[2][3][4]
  1. 病歴(発症様式、体位や頭位など増悪因子・軽快因子、持続時間)を聴取して、3つの型(急性前庭症候群:AVS、自発性発作性前庭症候群:s-EVS、誘発性発作性前庭症候群:t-EVS)の前庭症候群に分類するアプローチ(TiTrATE、あるいはATTEST)が提唱されている[5][6]
 
 
 
  1. 第⼀ステップで、めまいの随伴症状、めまいのタイミングと誘発因⼦に焦点を当てて病歴聴取して全体像をとらえる。
  1. 多くの患者では、全⾝性疾患(中毒、代謝性疾患、感染症、⼼⾎管系疾患)が⽰唆される。このグループの患者に対しては、誤診を減らすために、まず短い診断的 “STOP” を行う。このステップでは、まず神経前庭症状(眼振、四肢失調、歩⾏/体幹失調)の有無を確認する。
  1. COVID-19と前庭性疾患に関する、28編の症例報告または症例集積研究と、28編の横断研究からなるシステマティックレビュー・メタ解析では、COVID-19でみられる回転性めまいの頻度は7.2% (CI: 0.01-26.4) と報告されている[7]
  1. 耳毒性を有する薬剤に、抗菌薬 (アミノグリコシド、グリコペプチド (腎機能障害ある時)、マクロライド系 (高用量、経静脈投与時) ) 、抗悪性腫瘍薬 (プラチナ製剤) 、ループ利尿薬、抗マラリア薬、NSAIDs、アセチルサリチル酸が挙げられる[8]
  1. 全⾝性疾患の可能性が高いと考えられる場合は、その疑われる診断に対する評価、治療を行う。
 
 
  1. 診断的 “STOP” が陽性の場合や、病歴が全⾝性疾患を示唆しない場合は、めまいのtimingとtriggerについて病歴聴取し、3つのカテゴリーのいずれかに分類する。
  1. AVS、t-EVSでは、⾝体所⾒で診断ができる事がしばしばある。s-EVSでは、病歴でTIAや他の疾患から前庭性片頭痛を区別することを試みる。
 
急性前庭症候群(Acute vestibular syndrome:AVS):
  1. 突然発症で、数日〜数週間持続するめまいで悪心・嘔吐、歩行の不安定性、眼振、頭部の動作の不耐性を伴う。

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文献 

Kiersten L Gurley, Jonathan A Edlow
Acute Dizziness.
Semin Neurol. 2019 Feb;39(1):27-40. doi: 10.1055/s-0038-1676857. Epub 2019 Feb 11.
Abstract/Text Dizziness is a common chief complaint with an extensive differential diagnosis that includes both benign and serious conditions. Physicians must distinguish the majority of patients who suffer from self-limiting conditions from those with serious illnesses that require acute treatment. The preferred approach to the diagnosis of an acutely dizzy patient emphasizes different aspects of the history to guide a focused physical examination, with the goal of differentiating benign peripheral vestibular conditions from dangerous posterior circulation strokes. Currently, misdiagnoses are frequent and diagnostic testing costs are high. This partly relates to use of an outdated diagnostic paradigm. This commonly used traditional approach relies on dizziness "symptom quality" or "type" (vertigo, presyncope, disequilibrium) to guide inquiry. It does not distinguish benign from dangerous causes and is inconsistent with current best evidence. A better approach categorizes patients into three groups based on timing and triggers. Each category has its own differential diagnosis and targeted bedside approach: (1) acute vestibular syndrome, where bedside physical examination differentiates vestibular neuritis from stroke; (2) spontaneous episodic vestibular syndrome, where associated symptoms help differentiate vestibular migraine from transient ischemic attack; and (3) triggered episodic vestibular syndrome, where the Dix-Hallpike and supine roll test help differentiate benign paroxysmal positional vertigo from posterior fossa structural lesions. The "timing and triggers" diagnostic approach for the acutely dizzy derives from current best evidence and offers the potential to reduce misdiagnosis while simultaneously decreasing diagnostic test overuse, unnecessary hospitalization, and incorrect treatments.

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
PMID 30743290
Kiersten L Gurley, Jonathan A Edlow
Diagnosis of Patients with Acute Dizziness.
Emerg Med Clin North Am. 2021 Feb;39(1):181-201. doi: 10.1016/j.emc.2020.09.011. Epub 2020 Nov 5.
Abstract/Text Using an algorithmic approach to acutely dizzy patients, physicians can often confidently make a specific diagnosis that leads to correct treatment and should reduce the misdiagnosis of cerebrovascular events. Emergency clinicians should try to become familiar with an approach that exploits timing and triggers as well as some basic "rules" of nystagmus. The gait should always be tested in all patients who might be discharged. Computed tomographic scans are unreliable to exclude posterior circulation stroke presenting as dizziness, and early MRI (within the first 72 hours) also misses 10% to 20% of these cases.

Copyright © 2020 Elsevier Inc. All rights reserved.
PMID 33218657
D A Drachman, C W Hart
An approach to the dizzy patient.
Neurology. 1972 Apr;22(4):323-34.
Abstract/Text
PMID 4401538
David E Newman-Toker, Lisa M Cannon, Matthew E Stofferahn, Richard E Rothman, Yu-Hsiang Hsieh, David S Zee
Imprecision in patient reports of dizziness symptom quality: a cross-sectional study conducted in an acute care setting.
Mayo Clin Proc. 2007 Nov;82(11):1329-40. doi: 10.4065/82.11.1329.
Abstract/Text OBJECTIVE: To quantify precision in patient reports of different attributes of dizziness.
PATIENTS AND METHODS: In a cross-sectional study, we interviewed consecutive adult patients with dizziness at 2 urban academic emergency departments (EDs) from July 2, 2005, to August 26, 2005. We excluded patients who were too sick for an interview or who posed a risk to the interviewer. We included those who were "dizzy, light-headed, or off-balance" for 7 days or less or previously "bothered" by the same conditions. We assessed descriptions of dizziness quality elicited by 4 questions in different formats (open-ended, multiresponse, single-choice, and directed). Clarity was assessed qualitatively (vague, circular) and quantitatively (overlap of types of dizziness). Consistency was measured by frequency of mismatched responses across question formats. Reliability was determined by test-retest.
RESULTS: Of 1,342 patients screened, 872 (65%) were dizzy, light-headed, or off-balance in the past 7 days (n=677) or previously bothered by dizziness (n=195). Among these 872 patients with dizziness, 44% considered dizziness "the main reason" or "part of the reason" for the ED visit. Open-ended descriptions were frequently vague or circular. A total of 62% selected more than 1 dizziness type on the multiresponse question. On the same question, 54% did not pick 1 or more types endorsed previously in open description. Of 218 patients not identifying vertigo, spinning, or motion on the first 3 questions, 70% confirmed "spinning or motion" on directed questioning. Asked to choose the single best descriptor, 52% picked a different response on retest approximately 6 minutes later. By comparison, reports of dizziness duration and triggers were clear, consistent, and reliable.
CONCLUSION: Descriptions of the quality of dizziness are unclear, inconsistent, and unreliable, casting doubt on the validity of the traditional approach to the patient with dizziness. Alternative approaches, emphasizing timing and triggers over type, should be investigated.

PMID 17976352
David E Newman-Toker, Jonathan A Edlow
TiTrATE: A Novel, Evidence-Based Approach to Diagnosing Acute Dizziness and Vertigo.
Neurol Clin. 2015 Aug;33(3):577-99, viii. doi: 10.1016/j.ncl.2015.04.011.
Abstract/Text Diagnosing dizziness can be challenging, and the consequences of missing dangerous causes, such as stroke, can be substantial. Most physicians use a diagnostic paradigm developed more than 40 years ago that focuses on the type of dizziness, but this approach is flawed. This article proposes a new paradigm based on symptom timing, triggers, and targeted bedside eye examinations (TiTrATE). Patients fall into 1 of 4 major syndrome categories, each with its own differential diagnosis and set of targeted examination techniques that help make a specific diagnosis. Following an evidence-based approach could help reduce the frequency of misdiagnosis of serious causes of dizziness. In the spirit of the flipped classroom, the editors of this Neurologic Clinics issue on emergency neuro-otology have assembled a collection of unknown cases to be accessed electronically in multimedia format. By design, cases are not linked with specific articles, to avoid untoward cueing effects for the learner. The cases are real and are meant to demonstrate and reinforce lessons provided in this and subsequent articles. In addition to pertinent elements of medical history, cases include videos of key examination findings.

Copyright © 2015 Elsevier Inc. All rights reserved.
PMID 26231273
Jonathan A Edlow
A New Approach to the Diagnosis of Acute Dizziness in Adult Patients.
Emerg Med Clin North Am. 2016 Nov;34(4):717-742. doi: 10.1016/j.emc.2016.06.004. Epub 2016 Sep 7.
Abstract/Text Dizziness is a common chief complaint in emergency medicine. The differential diagnosis is broad and includes serious conditions, such as stroke, cardiac arrhythmia, hypovolemic states, and acute toxic and metabolic disturbances. Emergency physicians must distinguish the majority of patients who suffer from benign self-limiting conditions from those with serious illnesses that require acute treatment. Misdiagnoses are frequent and diagnostic test costs high. The traditional approach does not distinguish benign from dangerous causes and is not consistent with best current evidence. This article presents a new approach to the diagnosis of acutely dizzy patients that highly leverages the history and the physical examination.

Copyright © 2016 Elsevier Inc. All rights reserved.
PMID 27741985
Ibrahim Almufarrij, Kevin J Munro
One year on: an updated systematic review of SARS-CoV-2, COVID-19 and audio-vestibular symptoms.
Int J Audiol. 2021 Dec;60(12):935-945. doi: 10.1080/14992027.2021.1896793. Epub 2021 Mar 22.
Abstract/Text OBJECTIVE: The aim was to systematically review the literature to December 2020, in order to provide a timely summary of evidence on SARS-CoV-2, COVID-19 and audio-vestibular symptoms.
DESIGN: The protocol was registered in the International Prospective Register of Systematic Reviews. The methods were developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Risk of bias was assessed using the National Institutes of Heath quality assessment tools.
STUDY SAMPLE: After rejecting 850 records, 28 case reports/series and 28 cross-sectional studies met the inclusion criteria.
RESULTS: There are multiple reports of hearing loss (e.g. sudden sensorineural), tinnitus and rotatory vertigo in adults having a wide range of COVID-19 symptom severity. The pooled estimate of prevalence based primarily on retrospective recall of symptoms, was 7.6% (CI: 2.5-15.1), 14.8% (CI: 6.3-26.1) and 7.2% (CI: 0.01-26.4), for hearing loss, tinnitus and rotatory vertigo, respectively. However, these could be an over-estimate because it was not always clear that studies report a change in symptom.
CONCLUSION: There are multiple reports of audio-vestibular symptoms associated with COVID-19. However, there is a dearth of high-quality studies comparing COVID-19 cases and controls.
REVIEW REGISTRATION: Prospective Register of Systematic Reviews (PROSPERO); registration number CRD42020227038).

PMID 33750252
G Altissimi, A Colizza, G Cianfrone, M de Vincentiis, A Greco, S Taurone, A Musacchio, A Ciofalo, R Turchetta, D Angeletti, M Ralli
Drugs inducing hearing loss, tinnitus, dizziness and vertigo: an updated guide.
Eur Rev Med Pharmacol Sci. 2020 Aug;24(15):7946-7952. doi: 10.26355/eurrev_202008_22477.
Abstract/Text OBJECTIVE: The awareness of audio-vestibular side effects of drugs, such as hearing loss, tinnitus, dizziness and vertigo, has widely increased in the recent years. The present guide represents an update of the previous documents published by the authors in 2005 and 2011 on drug-induced ototoxicity and vestibulotoxicity.
MATERIALS AND METHODS: The authors performed a comprehensive analysis of audio-vestibular side effects of commercially available drugs based on the British National Formulary, a pharmaceutical reference book that contains a wide range of useful information and advice on prescription and pharmacology.
RESULTS: Commercially available drugs and their active principles have been classified based on their audio-vestibular side effects, as reported by the pharmaceutical companies and/or health agencies. Drugs have been categorized based on the field of application, the therapeutic indication and the pharmacological properties.
CONCLUSIONS: General practitioners, otolaryngology, neurology and audiology specialists should be aware of possible audio-vestibular side effects of drugs, such as hearing loss, tinnitus, dizziness and vertigo. The present guide represents a practical tool to rapidly identify potential audio-vestibular side effects of drugs as reported by the pharmaceutical companies and/or health agencies.

PMID 32767320
Jes Olesen
International Classification of Headache Disorders.
Lancet Neurol. 2018 May;17(5):396-397. doi: 10.1016/S1474-4422(18)30085-1. Epub 2018 Mar 14.
Abstract/Text
PMID 29550365
Hyo-Jung Kim, Jeong-Mi Song, Liqun Zhong, Xu Yang, Ji-Soo Kim
Questionnaire-based diagnosis of benign paroxysmal positional vertigo.
Neurology. 2020 Mar 3;94(9):e942-e949. doi: 10.1212/WNL.0000000000008876. Epub 2019 Dec 30.
Abstract/Text OBJECTIVES: To develop a simple questionnaire for self-diagnosis of benign paroxysmal positional vertigo (BPPV).
METHODS: We developed a questionnaire that consisted of 6 questions, the first 3 to diagnose BPPV and the next 3 to determine the involved canal and type of BPPV. From 2016 to 2017, 578 patients with dizziness completed the questionnaire before the positional tests, a gold standard for diagnosis of BPPV, at the Dizziness Clinic of Seoul National University Bundang Hospital.
RESULTS: Of the 578 patients, 200 were screened to have BPPV and 378 were screened to have dizziness/vertigo due to disorders other than BPPV. Of the 200 patients with a questionnaire-based diagnosis of BPPV, 160 (80%) were confirmed to have BPPV with positional tests. Of the 378 patients with a questionnaire-based diagnosis of non-BPPV, 24 (6.3%) were found to have BPPV with positional tests. Thus, the sensitivity, specificity, and precision of the questionnaires for the diagnosis of BPPV were 87.0%, 89.8%, and 80.0% (121 of 161, 95% confidence interval 74.5%-85.5%). Of the 200 patients with a questionnaire-based diagnosis of BPPV, 30 failed to respond to the questions 4 through 6 to determine the involved canal and type of BPPV. The questionnaire and positional tests showed the same results for the subtype and affected side of BPPV in 121 patients (121 of 170, 71.2%).
CONCLUSION: The accuracy of questionnaire-based diagnosis of BPPV is acceptable.
CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that, in patients with dizziness, a questionnaire can diagnose BPPV with a sensitivity of 87.0% and a specificity of 89.8%.

© 2019 American Academy of Neurology.
PMID 31888973
Kevin A Kerber, Devin L Brown, Lynda D Lisabeth, Melinda A Smith, Lewis B Morgenstern
Stroke among patients with dizziness, vertigo, and imbalance in the emergency department: a population-based study.
Stroke. 2006 Oct;37(10):2484-7. doi: 10.1161/01.STR.0000240329.48263.0d. Epub 2006 Aug 31.
Abstract/Text BACKGROUND AND PURPOSE: Dizziness, vertigo, and imbalance are common presenting symptoms in the emergency department. Stroke is a leading concern even when these symptoms occur in isolation. The objective of the present study was to determine the "real-world" proportion of stroke among patients presenting to the emergency department with these dizziness symptoms (DS).
METHODS: From a population-based study, patients >44 years of age presenting with DS to the emergency department, or directly admitted to the hospital, were identified. Demographics, the frequency of new cerebrovascular events, and the frequency of isolated DS (ie DS with no other stroke screening term or accompanying neurologic signs or symptoms) were assessed. Multivariable logistic regression was used to evaluate the association of age, gender, ethnicity, and isolated DS with stroke/transient ischemic attack (TIA). The association of the presenting symptoms with stroke/TIA was also assessed.
RESULTS: Stroke/TIA was diagnosed in 3.2% (53 of 1666) of all patients with DS. Only 0.7% (9 of 1297) of those with isolated DS had a stroke/TIA. Patients with stroke/TIA were slightly older than those without stroke/TIA (69.3+/-11.7 vs 65.3+/-12.9, P=0.02). Male gender was associated with stroke/TIA, whereas isolated DS was negatively associated with stroke/TIA. Patients with imbalance (dizziness as referent) were more likely to have stroke/TIA.
CONCLUSIONS: The proportion of cerebrovascular events in patients presenting with dizziness, vertigo, or imbalance is very low. Isolated dizziness, vertigo, or imbalance strongly predicts a noncerebrovascular cause. The symptom of imbalance is a predictor of stroke/TIA.

PMID 16946161
H Lee, S-I Sohn, Y-W Cho, S-R Lee, B-H Ahn, B-R Park, R W Baloh
Cerebellar infarction presenting isolated vertigo: frequency and vascular topographical patterns.
Neurology. 2006 Oct 10;67(7):1178-83. doi: 10.1212/01.wnl.0000238500.02302.b4.
Abstract/Text OBJECTIVE: To determine the frequency of cerebellar infarction mimicking vestibular neuritis (VN), the pattern of clinical presentation, and the territory of the cerebellar infarction when it simulates VN.
METHODS: We studied 240 consecutive cases of isolated cerebellar infarction in the territories of the cerebellar arteries diagnosed by brain MRI from the acute stroke registry at the Keimyung University Dongsan Medical Center.
RESULTS: We identified 25 patients (10.4%) with isolated cerebellar infarction who had clinical features suggesting VN. Two types of cerebellar infarction simulating VN were found: isolated spontaneous prolonged vertigo with imbalance as a sole manifestation of cerebellar infarction (n = 24) and isolated spontaneous prolonged vertigo with imbalance as an initial manifestation of cerebellar infarction (n = 1) followed by delayed neurologic deficits 2 days after the onset. The cerebellar infarction territory most commonly involved was the medial branch of the posterior inferior cerebellar artery territory (24/25: 96%), followed by the anterior inferior cerebellar artery territory (1/25: 4%). None of patients with infarcts in the territory of the superior cerebellar artery or multiple cerebellar arteries showed isolated spontaneous prolonged vertigo.
CONCLUSIONS: Cerebellar infarction simulating vestibular neuritis is more common than previously thought. Early recognition of the pseudo-vestibular neuritis of vascular cause may allow specific management.

PMID 17030749
D A Froehling, M D Silverstein, D N Mohr, C W Beatty
The rational clinical examination. Does this dizzy patient have a serious form of vertigo?
JAMA. 1994 Feb 2;271(5):385-8.
Abstract/Text
PMID 8283588
Hyung Lee, Ji Soo Kim, Eun-Ji Chung, Hyon-Ah Yi, In-Sung Chung, Seong-Ryong Lee, Je-Young Shin
Infarction in the territory of anterior inferior cerebellar artery: spectrum of audiovestibular loss.
Stroke. 2009 Dec;40(12):3745-51. doi: 10.1161/STROKEAHA.109.564682. Epub 2009 Sep 24.
Abstract/Text BACKGROUND AND PURPOSE: To define the detailed spectrum of audiovestibular dysfunction in anterior inferior cerebellar artery territory infarction.
METHODS: Over 8.5 years, we prospectively identified 82 consecutive patients with anterior inferior cerebellar artery territory infarction diagnosed by MRI. Each patient completed a standardized audiovestibular questionnaire and underwent a neuro-otologic evaluation, including bithermal caloric tests and pure tone audiogram.
RESULTS: All but 2 (80 of 82 [98%]) patients had acute prolonged vertigo and vestibular dysfunction of peripheral, central, or combined origin. The most common pattern of audiovestibular dysfunction was the combined loss of auditory and vestibular function (n=49 [60%]). A selective loss of vestibular (n=4 [5%]) or cochlear (n=3 [4%]) function was rarely observed. We could classify anterior inferior cerebellar artery territory infarction into 7 subgroups according to the patterns of neuro-otological presentations: (1) acute prolonged vertigo with audiovestibular loss (n=35); (2) acute prolonged vertigo with audiovestibular loss preceded by an episode(s) of transient vertigo/auditory disturbance within 1 month before the infarction (n=13); (3) acute prolonged vertigo and isolated auditory loss without vestibular loss (n=3); (4) acute prolonged vertigo and isolated vestibular loss without auditory loss (n=4); (5) acute prolonged vertigo but without documented audiovestibular loss (n=24); (6) acute prolonged vertigo and isolated audiovestibular loss without any other neurological symptoms/signs (n=1); and (7) nonvestibular symptoms with normal audiovestibular function (n=2).
CONCLUSIONS: Infarction in the anterior inferior cerebellar artery territory can present with a broad spectrum of audiovestibular dysfunctions. Unlike a viral cause, labyrinthine dysfunction of a vascular cause usually leads to combined loss of both auditory and vestibular functions.

PMID 19797177
Sean I Savitz, Louis R Caplan, Jonathan A Edlow
Pitfalls in the diagnosis of cerebellar infarction.
Acad Emerg Med. 2007 Jan;14(1):63-8. doi: 10.1197/j.aem.2006.06.060.
Abstract/Text BACKGROUND: Cerebellar infarctions are an important cause of neurologic disease. Failure to recognize and rapidly diagnose cerebellar infarction may lead to serious morbidity and mortality due to hydrocephalus and brain stem infarction.
OBJECTIVES: To identify sources of preventable medical errors, the authors obtained pilot data on cerebellar ischemic strokes that were initially misdiagnosed in the emergency department.
METHODS: Fifteen cases of misdiagnosed cerebellar infarctions were collected, all seen, or reviewed by the authors during a five-year period. For each patient, they report the presenting symptoms, the findings on neurologic examination performed in the emergency department, specific areas of the examination not performed or documented, diagnostic testing, the follow-up course after misdiagnosis, and outcome. The different types of errors leading to misdiagnosis are categorized.
RESULTS: Half of the patients were younger than 50 years and presented with headache and dizziness. All patients had either incomplete or poorly documented neurologic examinations. Almost all patients had a computed tomographic scan of the head interpreted as normal, and most of these patients underwent subsequent magnetic resonance imaging showing cerebellar infarction. The initial incorrect diagnoses included migraine, toxic encephalopathy, gastritis, meningitis, myocardial infarction, and polyneuropathy. The overall mortality in this patient cohort was 40%. Among the survivors, about 50% had disabling deficits. Pitfalls leading to misdiagnosis involved the clinical evaluation, diagnostic testing, and establishing a diagnosis and disposition.
CONCLUSIONS: This study demonstrates how the diagnosis of cerebellar infarction can be missed or delayed in patients presenting to the emergency department.

PMID 17200515
James A Nelson, Erik Viirre
The clinical differentiation of cerebellar infarction from common vertigo syndromes.
West J Emerg Med. 2009 Nov;10(4):273-7.
Abstract/Text This article summarizes the emergency department approach to diagnosing cerebellar infarction in the patient presenting with vertigo. Vertigo is defined and identification of a vertigo syndrome is discussed. The differentiation of common vertigo syndromes such as benign paroxysmal positional vertigo, Meniere's disease, migrainous vertigo, and vestibular neuritis is summarized. Confirmation of a peripheral vertigo syndrome substantially lowers the likelihood of cerebellar infarction, as do indicators of a peripheral disorder such as an abnormal head impulse test. Approximately 10% of patients with cerebellar infarction present with vertigo and no localizing neurologic deficits. The majority of these may have other signs of central vertigo, specifically direction-changing nystagmus and severe ataxia.

PMID 20046249
Jorge C Kattah, Arun V Talkad, David Z Wang, Yu-Hsiang Hsieh, David E Newman-Toker
HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging.
Stroke. 2009 Nov;40(11):3504-10. doi: 10.1161/STROKEAHA.109.551234. Epub 2009 Sep 17.
Abstract/Text BACKGROUND AND PURPOSE: Acute vestibular syndrome (AVS) is often due to vestibular neuritis but can result from vertebrobasilar strokes. Misdiagnosis of posterior fossa infarcts in emergency care settings is frequent. Bedside oculomotor findings may reliably identify stroke in AVS, but prospective studies have been lacking.
METHODS: The authors conducted a prospective, cross-sectional study at an academic hospital. Consecutive patients with AVS (vertigo, nystagmus, nausea/vomiting, head-motion intolerance, unsteady gait) with >or=1 stroke risk factor underwent structured examination, including horizontal head impulse test of vestibulo-ocular reflex function, observation of nystagmus in different gaze positions, and prism cross-cover test of ocular alignment. All underwent neuroimaging and admission (generally <72 hours after symptom onset). Strokes were diagnosed by MRI or CT. Peripheral lesions were diagnosed by normal MRI and clinical follow-up.
RESULTS: One hundred one high-risk patients with AVS included 25 peripheral and 76 central lesions (69 ischemic strokes, 4 hemorrhages, 3 other). The presence of normal horizontal head impulse test, direction-changing nystagmus in eccentric gaze, or skew deviation (vertical ocular misalignment) was 100% sensitive and 96% specific for stroke. Skew was present in 17% and associated with brainstem lesions (4% peripheral, 4% pure cerebellar, 30% brainstem involvement; chi(2), P=0.003). Skew correctly predicted lateral pontine stroke in 2 of 3 cases in which an abnormal horizontal head impulse test erroneously suggested peripheral localization. Initial MRI diffusion-weighted imaging was falsely negative in 12% (all <48 hours after symptom onset).
CONCLUSIONS: Skew predicts brainstem involvement in AVS and can identify stroke when an abnormal horizontal head impulse test falsely suggests a peripheral lesion. A 3-step bedside oculomotor examination (HINTS: Head-Impulse-Nystagmus-Test-of-Skew) appears more sensitive for stroke than early MRI in AVS.

PMID 19762709
Jonathan A Edlow
Diagnosing Patients With Acute-Onset Persistent Dizziness.
Ann Emerg Med. 2018 May;71(5):625-631. doi: 10.1016/j.annemergmed.2017.10.012. Epub 2017 Nov 24.
Abstract/Text
PMID 29174835
Robert Ohle, Renee-Anne Montpellier, Virginie Marchadier, Aidan Wharton, Sarah McIsaac, Mackenzie Anderson, David Savage
Can Emergency Physicians Accurately Rule Out a Central Cause of Vertigo Using the HINTS Examination? A Systematic Review and Meta-analysis.
Acad Emerg Med. 2020 Sep;27(9):887-896. doi: 10.1111/acem.13960. Epub 2020 Apr 8.
Abstract/Text INTRODUCTION: Dizziness is a common complaint presented in the emergency department (ED). A subset of these patients will present with acute vestibular syndrome (AVS). AVS is a clinical syndrome defined by the presence of vertigo, nystagmus, head motion intolerance, ataxia, and nausea/vomiting. These symptoms are most often due to benign vestibular neuritis; however, they can be a sign of a dangerous central cause, i.e., vertebrobasilar stroke. The Head Impulse test, Nystagmus, Test of Skew (HINTS) examination has been proposed as a bedside test for frontline clinicians to rule out stroke in those presenting with AVS. Our objective was to assess the diagnostic accuracy of the HINTS examination to rule out a central cause of vertigo in an adult population presenting to the ED with AVS. Our aim was to assess the diagnostic accuracy when performed by emergency physicians versus neurologists.
METHODS: We searched PubMed, Medline, Embase, the Cochrane database, and relevant conference abstracts from 2009 to September 2019 and performed hand searches. No restrictions for language or study type were imposed. Prospective studies with patients presenting with AVS using criterion standard of computed tomography and/or magnetic resonance imaging were selected for review. Two independent reviewers extracted data from relevant studies. Studies were combined if low clinical and statistical heterogeneity was present. Study quality was assessed using the QUADAS-2 tool. Random effects meta-analysis was performed using RevMan 5 and SAS 9.3.
RESULTS: A total of five studies with 617 participants met the inclusion criteria. The mean (±SD) study length was 5.3 (±3.3) years. Prevalence of vertebrobasilar stroke ranged 9.3% to 44% (mean ± SD = 39.1% ± 17.1%). The most common diagnoses were vertebrobasilar stroke (mean ± SD = 34.8% ± 17.1%), peripheral cause (mean ± SD = 30.9% ± 16%), and intracerebral hemorrhage (mean ± SD = 2.2% ± 0.5%). The HINTS examination, when performed by neurologists, had a sensitivity of 96.7% (95% CI = 93.1% to 98.5%, I2  = 0%) and specificity of 94.8% (95% CI = 91% to 97.1%, I2  = 0%). When performed by a cohort of physicians including both emergency physicians (board certified) and neurologists (fellowship trained in neurootology or vascular neurology) the sensitivity was 83% (95% CI = 63% to 95%) and specificity was 44% (95% CI = 36% to 51%).
CONCLUSIONS: The HINTS examination, when used in isolation by emergency physicians, has not been shown to be sufficiently accurate to rule out a stroke in those presenting with AVS.

© 2020 by the Society for Academic Emergency Medicine.
PMID 32167642
Neil Bhattacharyya, Samuel P Gubbels, Seth R Schwartz, Jonathan A Edlow, Hussam El-Kashlan, Terry Fife, Janene M Holmberg, Kathryn Mahoney, Deena B Hollingsworth, Richard Roberts, Michael D Seidman, Robert W Prasaad Steiner, Betty Tsai Do, Courtney C J Voelker, Richard W Waguespack, Maureen D Corrigan
Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update).
Otolaryngol Head Neck Surg. 2017 Mar;156(3_suppl):S1-S47. doi: 10.1177/0194599816689667.
Abstract/Text Objective This update of a 2008 guideline from the American Academy of Otolaryngology-Head and Neck Surgery Foundation provides evidence-based recommendations to benign paroxysmal positional vertigo (BPPV), defined as a disorder of the inner ear characterized by repeated episodes of positional vertigo. Changes from the prior guideline include a consumer advocate added to the update group; new evidence from 2 clinical practice guidelines, 20 systematic reviews, and 27 randomized controlled trials; enhanced emphasis on patient education and shared decision making; a new algorithm to clarify action statement relationships; and new and expanded recommendations for the diagnosis and management of BPPV. Purpose The primary purposes of this guideline are to improve the quality of care and outcomes for BPPV by improving the accurate and efficient diagnosis of BPPV, reducing the inappropriate use of vestibular suppressant medications, decreasing the inappropriate use of ancillary testing such as radiographic imaging, and increasing the use of appropriate therapeutic repositioning maneuvers. The guideline is intended for all clinicians who are likely to diagnose and manage patients with BPPV, and it applies to any setting in which BPPV would be identified, monitored, or managed. The target patient for the guideline is aged ≥18 years with a suspected or potential diagnosis of BPPV. The primary outcome considered in this guideline is the resolution of the symptoms associated with BPPV. Secondary outcomes considered include an increased rate of accurate diagnoses of BPPV, a more efficient return to regular activities and work, decreased use of inappropriate medications and unnecessary diagnostic tests, reduction in recurrence of BPPV, and reduction in adverse events associated with undiagnosed or untreated BPPV. Other outcomes considered include minimizing costs in the diagnosis and treatment of BPPV, minimizing potentially unnecessary return physician visits, and maximizing the health-related quality of life of individuals afflicted with BPPV. Action Statements The update group made strong recommendations that clinicians should (1) diagnose posterior semicircular canal BPPV when vertigo associated with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver, performed by bringing the patient from an upright to supine position with the head turned 45° to one side and neck extended 20° with the affected ear down, and (2) treat, or refer to a clinician who can treat, patients with posterior canal BPPV with a canalith repositioning procedure. The update group made a strong recommendation against postprocedural postural restrictions after canalith repositioning procedure for posterior canal BPPV. The update group made recommendations that the clinician should (1) perform, or refer to a clinician who can perform, a supine roll test to assess for lateral semicircular canal BPPV if the patient has a history compatible with BPPV and the Dix-Hallpike test exhibits horizontal or no nystagmus; (2) differentiate, or refer to a clinician who can differentiate, BPPV from other causes of imbalance, dizziness, and vertigo; (3) assess patients with BPPV for factors that modify management, including impaired mobility or balance, central nervous system disorders, a lack of home support, and/or increased risk for falling; (4) reassess patients within 1 month after an initial period of observation or treatment to document resolution or persistence of symptoms; (5) evaluate, or refer to a clinician who can evaluate, patients with persistent symptoms for unresolved BPPV and/or underlying peripheral vestibular or central nervous system disorders; and (6) educate patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up. The update group made recommendations against (1) radiographic imaging for a patient who meets diagnostic criteria for BPPV in the absence of additional signs and/or symptoms inconsistent with BPPV that warrant imaging, (2) vestibular testing for a patient who meets diagnostic criteria for BPPV in the absence of additional vestibular signs and/or symptoms inconsistent with BPPV that warrant testing, and (3) routinely treating BPPV with vestibular suppressant medications such as antihistamines and/or benzodiazepines. The guideline update group provided the options that clinicians may offer (1) observation with follow-up as initial management for patients with BPPV and (2) vestibular rehabilitation, either self-administered or with a clinician, in the treatment of BPPV.

PMID 28248609
Malcolm P Hilton, Darren K Pinder
The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo.
Cochrane Database Syst Rev. 2014 Dec 8;(12):CD003162. doi: 10.1002/14651858.CD003162.pub3. Epub 2014 Dec 8.
Abstract/Text BACKGROUND: This is an update of a Cochrane Review first published in The Cochrane Library in Issue 1, 2002 and previously updated in 2004 and 2007.Benign paroxysmal positional vertigo (BPPV) is a syndrome characterised by short-lived episodes of vertigo in association with rapid changes in head position. It is a common cause of vertigo presenting to primary care and specialist otolaryngology clinics. Current treatment approaches include rehabilitative exercises and physical manoeuvres, including the Epley manoeuvre.
OBJECTIVES: To assess the effectiveness of the Epley manoeuvre for posterior canal BPPV.
SEARCH METHODS: We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 23 January 2014.
SELECTION CRITERIA: Randomised controlled trials of the Epley manoeuvre versus placebo, no treatment or other active treatment for adults diagnosed with posterior canal BPPV (including a positive Dix-Hallpike test). The primary outcome of interest was complete resolution of vertigo symptoms. Secondary outcomes were conversion of a 'positive' Dix-Hallpike test to a 'negative' Dix-Hallpike test and adverse effects of treatment.
DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by The Cochrane Collaboration.
MAIN RESULTS: We included 11 trials in the review with a total of 745 patients.Five studies compared the efficacy of the Epley manoeuvre against a sham manoeuvre, three against other particle repositioning manoeuvres (Semont, Brandt-Daroff and Gans) and three against a control (no treatment, medication only, postural restriction). Patients were treated in hospital otolaryngology departments in eight studies and family practices in two studies. All patients were adults aged 18 to 90 years old, with a sex ratio of 1:1.5 male to female.There was a low risk of overall bias in the studies included. All studies were randomised with six applying sealed envelope or external allocation techniques. Eight of the trials blinded the assessors to the participants' treatment group and data on all outcomes for all participants were reported in eight of the 11 studies. Complete resolution of vertigo Complete resolution of vertigo occurred significantly more often in the Epley treatment group when compared to a sham manoeuvre or control (odds ratio (OR) 4.42, 95% confidence interval (CI) 2.62 to 7.44; five studies, 273 participants); the proportion of patients resolving increased from 21% to 56%. None of the trials comparing Epley versus other particle repositioning manoeuvres reported vertigo resolution as an outcome. Conversion of Dix-Hallpike positional test result from positive to negative Conversion from a positive to a negative Dix-Hallpike test significantly favoured the Epley treatment group when compared to a sham manoeuvre or control (OR 9.62, 95% CI 6.0 to 15.42; eight studies, 507 participants). There was no difference when comparing the Epley with the Semont manoeuvre (two studies, 117 participants) or the Epley with the Gans manoeuvre (one study, 58 participants). In one study a single Epley treatment was more effective than a week of three times daily Brandt-Daroff exercises (OR 12.38, 95% CI 4.32 to 35.47; 81 participants). Adverse effects Adverse effects were infrequently reported. There were no serious adverse effects of treatment. Rates of nausea during the repositioning manoeuvre varied from 16.7% to 32%. Some patients were unable to tolerate the manoeuvres because of cervical spine problems.
AUTHORS' CONCLUSIONS: There is evidence that the Epley manoeuvre is a safe, effective treatment for posterior canal BPPV, based on the results of 11, mostly small, randomised controlled trials with relatively short follow-up. There is a high recurrence rate of BPPV after treatment (36%). Outcomes for Epley manoeuvre treatment are comparable to treatment with Semont and Gans manoeuvres, but superior to Brandt-Daroff exercises.

PMID 25485940
K A Marill, M J Walsh, B K Nelson
Intravenous Lorazepam versus dimenhydrinate for treatment of vertigo in the emergency department: a randomized clinical trial.
Ann Emerg Med. 2000 Oct;36(4):310-9. doi: 10.1067/mem.2000.110580.
Abstract/Text STUDY OBJECTIVE: To determine whether lorazepam is more effective than dimenhydrinate in relieving the symptom of vertigo in the emergency department setting.
METHODS: A prospective, randomized, double-blind trial of intravenous lorazepam versus dimenhydrinate therapy was conducted in the ED of a county-owned, university-affiliated hospital. All adult patients who presented between January 24, 1998, and May 23, 1999, with the symptom of vertigo were eligible for inclusion. The intervention was varying the intravenous treatment between lorazepam, 2 mg, and dimenhydrinate, 50 mg. All patients received intravenous infusion of Ringer's lactate solution at a rate of 100 mL/h. Adequacy of randomization to the 2 treatment groups was assessed by comparing the patients' relevant baseline history, physical examination, and symptoms. The predetermined primary outcome measurement was the patient's sensation of "vertigo with ambulation" 1 and 2 hours after treatment. Secondary outcome measurements included vertigo while lying, sitting, and turning the head, ability to ambulate as judged by the enrolling physician, and sensation of nausea and drowsiness 1 and 2 hours after treatment, and whether the patient was "ready to go home" per patient report or physician assessment 2 hours after treatment. All patient symptoms were reported on 10-point scales. Outcome measurements were compared between the 2 treatment groups with a 2-way repeated-measures analysis of variance, Student's t test, Mann-Whitney U, and chi(2) test as appropriate.
RESULTS: Ten patients refused entry into the study, 16 were excluded, and 74 were enrolled, treated, and included in the analysis. One enrolled patient had evidence of vertigo of central origin. The pretreatment values of vertigo with ambulation were strongly correlated with the patient's ability to ambulate (P <.001), suggesting good internal validity. The patients randomly assigned to the lorazepam group were sicker based on their pretreatment symptoms and ability to ambulate, and this may have biased the study results. The patients' symptom of "vertigo with ambulation" decreased 1.5 units more (95% confidence interval [CI] 0 to 3.0) on average on a 10-point scale 2 hours after treatment in the dimenhydrinate group. All other measures of vertigo also decreased more in the dimenhydrinate group, although the differences were not statistically significant. At 2 hours after treatment, the patients' ability to ambulate was better in the dimenhydrinate group (P <.001), and 17% (95% CI -2 to 36) more patients in this group were "ready to go home." Patients in the lorazepam group experienced a 1.8-unit (95% CI 0.2 to 3.4) greater increase in drowsiness 2 hours after treatment.
CONCLUSION: Our results suggest that dimenhydrinate was more effective in relieving vertigo and less sedating than lorazepam at the intravenous doses administered in this study. Dimenhydrinate appears to be the preferred medicine for patients who present to the ED with vertigo likely to be of peripheral origin.

PMID 11020677
A Soto Varela, J Bartual Magro, S Santos Pérez, M Vélez Regueiro, R Lechuga García, A Pérez-Carro Ríos, L Caballero
Benign paroxysmal vertigo: a comparative prospective study of the efficacy of Brandt and Daroff exercises, Semont and Epley maneuver.
Rev Laryngol Otol Rhinol (Bord). 2001;122(3):179-83.
Abstract/Text We performed a prospective study to evaluate the efficacy of three physical treatments for benign paroxysmal positional vertigo: Brandt & Daroff habituation exercises, the Semont manoevre (intended as a statoconia-detachment maneuver), and the Epley maneuver (intended as a statoconia-repositioning maneuver). A total of 106 BPPV patients were randomly assigned to one of the three treatment groups, and responses were evaluated one week, one month and three months after the initial treatment. At the one-week follow-up, similar cure rates were obtained with the Semont and Epley maneuver (74% and 71% respectively), both cure rates being significantly higher than that obtained with Brandt & Daroff exercises (24%). By the three-month follow-up, the cure rate obtained with the Epley maneuver was higher (93%) than that obtained with the Semont maneuver (77%), though both remained higher than that obtained with the Brandt & Daroff maneuver (62%). However, the proportion of initially responding patients showing subsequent relapse was lower among patients treated by the Semont maneuver than among patients treated by the Epley maneuver. In view of these findings, we propose a treatment algorithm for patients with BPPV.

PMID 11799859
Julio A Chalela, Chelsea S Kidwell, Lauren M Nentwich, Marie Luby, John A Butman, Andrew M Demchuk, Michael D Hill, Nicholas Patronas, Lawrence Latour, Steven Warach
Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison.
Lancet. 2007 Jan 27;369(9558):293-8. doi: 10.1016/S0140-6736(07)60151-2.
Abstract/Text BACKGROUND: Although the use of magnetic resonance imaging (MRI) for the diagnosis of acute stroke is increasing, this method has not proved more effective than computed tomography (CT) in the emergency setting. We aimed to prospectively compare CT and MRI for emergency diagnosis of acute stroke.
METHODS: We did a single-centre, prospective, blind comparison of non-contrast CT and MRI (with diffusion-weighted and susceptibility weighted images) in a consecutive series of patients referred for emergency assessment of suspected acute stroke. Scans were independently interpreted by four experts, who were unaware of clinical information, MRI-CT pairings, and follow-up imaging.
RESULTS: 356 patients, 217 of whom had a final clinical diagnosis of acute stroke, were assessed. MRI detected acute stroke (ischaemic or haemorrhagic), acute ischaemic stroke, and chronic haemorrhage more frequently than did CT (p<0.0001, for all comparisons). MRI was similar to CT for the detection of acute intracranial haemorrhage. MRI detected acute ischaemic stroke in 164 of 356 patients (46%; 95% CI 41-51%), compared with CT in 35 of 356 patients (10%; 7-14%). In the subset of patients scanned within 3 h of symptom onset, MRI detected acute ischaemic stroke in 41 of 90 patients (46%; 35-56%); CT in 6 of 90 (7%; 3-14%). Relative to the final clinical diagnosis, MRI had a sensitivity of 83% (181 of 217; 78-88%) and CT of 26% (56 of 217; 20-32%) for the diagnosis of any acute stroke.
INTERPRETATION: MRI is better than CT for detection of acute ischaemia, and can detect acute and chronic haemorrhage; therefore it should be the preferred test for accurate diagnosis of patients with suspected acute stroke. Because our patient sample encompassed the range of disease that is likely to be encountered in emergency cases of suspected stroke, our results are directly applicable to clinical practice.

PMID 17258669

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