Dr. Jeff Hersh
Q: When my cousin developed dizziness and nausea she went to the emergency room and they told her she bad benign Vertigo. She got better with their treatments and was discharged with a prescription. When my dad developed similar symptoms we eventually took him to the ER and they said he had a stroke and admitted him. How can the diagnosis be so different?
A: Dizziness is a common complaint, accounting for more than two of every 100 ER visits. Although anyone can get episodes of dizziness, it is more common with age, eventually occurring in over 40 percent of people over age 40. Not all “dizziness” is the same. Some people describe “lightheadedness” as dizziness, while others describe Vertigo, a feeling of movement, either of the patient themselves or their surroundings. We have all had this feeling when we spun ourselves around as part of a child’s game.
The vestibular system, made up of three fluid filled loops which are perpendicular to each other, is located in the inner ear and is able to sense the orientation of the body. Gravity causes the fluid level in each of these loops to change as the head moves, and the vestibular system Senses these changes. Of course, the sense of vision also gives information about the body’s Orientation (many of us have been in fun houses where the curved mirrors intentionally “disorient” us), as does proprioception (the sense of balance and alignment of our joints, telling us if we are leaning). The brain – particularly the cerebellum and brain Stem – interprets all this information and uses it to decide how the body is oriented and to achieve balance.
Peripheral Vertigo occurs when the brain interprets inconsistent signals within or between these sensory systems. Benign positional Vertigo is a type of peripheral Vertigo from the disruption of the free flow of fluid within one or more of the loops within the vestibular system. There are many other possible causes of peripheral vertigo, including inner ear disorders, Meniere’s disease, vestibular neuritis, labyrinthitis, migraine headaches, side effects of certain medications and many others.
Central Vertigo occurs when the brain’s central processing system is affected, for example from a central nervous system tumor, infection, trauma, stroke (even though this represents only 1 to 4 percent of all strokes), head injury, complication of certain medications or other conditions (for example multiple sclerosis).
When a patient is evaluated for Vertigo, the history and physical exam focus is on differentiating peripheral from central Vertigo. This is typically done by utilizing certain maneuvers during the exam, for example the Romberg and HINTS (head impulse test, nystagmus and skew deviation) tests. The results of these, as well as other findings on the history and physical exam, will help the clinician decide what type of Vertigo the patient has.
For patients with peripheral Vertigo, a thorough history and physical may be all that is required to make the diagnosis. For central Vertigo, or if the diagnosis is in doubt, Imaging tests (although a CT scan may be done initially, an MRI is more sensitive to evaluate causes of Vertigo) and / or other tests, for example tests to work up possible causes of a stroke (possibly including certain blood tests, certain heart tests like an ECG, echocardiogram, tests to evaluate for blood vessel narrowing such as an ultrasound, and / or other tests).
It sounds like your dad had central Vertigo and that is what made the evaluating clinician Suspicious of a stroke.
Most cases of peripheral Vertigo are self-limited (resolving on their own), hence treatment is aimed at Symptom control, usually with appropriate medications and / or specialized maneuvers (such as the Epley maneuver, a series of head tilts done to help “clear “blockage of the vestibular canals).
Patients with central Vertigo will have a more aggressive workup (as noted above), and the treatment determined by the underlying cause. If the patient does have a stroke, it is crucial to differentiate between a hemorrhagic stroke (where a damaged blood vessel bleeds into the brain; this is the less common type of accounting for about 10 to 15 percent of strokes) versus an ischemic stroke (where a blood vessel is blocked, typically by a clot or emboli, decreasing blood flow which interrupts oxygen and nutrient delivery to a part of the brain).
Ischemic stroke patients may be treated with immediate reperfusion therapy (to restart the blood supply to the affected part of the brain) with thrombolysis (using medications to “dissolve” the blood clot / embolism), mechanical removal of the clot / embolism (thrombectomy), and / or other medications / treatments. The specific treatment recommendation will depend on the specifics of the patient’s condition, including the severity of the symptoms, as well as how long it has been since the symptoms started (hence why being evaluated promptly is so important).
The prognosis of central vertigo depends on the underlying cause. For certain types of strokes (for example vertebrobasilar strokes), the prognosis is poor, with a mortality rate of over 85 percent, and many of the Survivors having significant residual morbidities.
If you develop dizziness, including true Vertigo, you should seek immediate medical care. Although now the causes of these symptoms are benign, more serious disorders such as a stroke, need to be ruled out.
Jeff Hersh, Ph.D., MD, can be reached at [email protected]