Clinical Notes : Neurology

22. Acute Vestibular Syndrome

Diagnosis of AVS

  • Usually sudden onset (may be hours)

  • Ongoing vertigo (lasting hours or days)

  • Worsened by changes in head position

  • Nausea and Vomit

  • Not walking normally (ataxia)

  • Spontaneous nystagmus

 

Etiology of AVS

2 causes of AVS

  • Peripheral cause (vestibular neuritis etc.) or

  • Central cause (posterior circulation stroke)

 

It is essential NOT to miss the posterior circulation stroke presenting as AVS

 

Diagnosis of posterior circulation stroke presenting as AVS

  • HINTS Examination

    • sensitivity 100%, specificity 96%) and is more sensitive than early MRI scanning

 

HINTS examination

  • Head Impulse test 

  • Nystagmus

  • Test of Skew

 

AVS indicative of vestibular neuritis (with HINTS examination)

  1. Nystagmus does not change direction when looking left vs right

  2. No vertical nystagmus as one eye is covered then the other (Test of Skew)

  3. Nystagmus with lag when head is rocked left and right then jerked left or right (Head Impulse Test)

 

AVS indicative of posterior circulation stroke ((with HINTS examination)

  1. Nystagmus changes direction when looking left vs right

  2. Vertical nystagmus as one eye is covered then the other (Test of Skew)

  3. No nystagmus when head is rocked left and right then jerked left or right (Head Impulse Test)

 
 
 
 
 
 

A basic, simplified approach to the dizzy patient

 

Nystagmus

  • In vestibular neuritis

    • Does not change direction when looking left and right

    • Usually horizontal (sometimes also rotatory)

      • Fast component away from affected ear

    • Increases looking away from affected ear

      • Decreases looking towards affected ear

  • In stroke

    • Changes direction

      • Left when looking left

      • Right when looking right

 

Test of Skew

  • Nystagmus in different directions as one eye is covered then the other

  • Horizontal nystagmus = vestibular neuritis

  • Vertical nystagmus = stroke

 

Head Impulse Test

  • The head is rockedleft and right, then jerked left or right

  • brings on nystagmus = vestibular neuritis

  • no nystagmus = stroke

 
 
 
 

Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome

Alexander A. Tarnutzer, Aaron L. Berkowitz Karen A. Robinson, Yu-Hsiang Hsieh,

David E. Newman-Toker

CMAJ, 2011, 183(9). June 2011

Access

 

Is it a stroke?

Graeme J Hankey, Winthrop professor of neurology; consultant neurologist12,

David J Blacker, clinical professor; consultant neurologist123

BMJ 2015;350:h56. November 2014.

Access

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