CHAPTER 80

Temporal Arteritis

Administer oral prednisone 80 mg. The patient should be

discharged home on prednisone 40 mg daily. Close

follow-up for biopsy and definitive diagnosis should

be arranged before the patient is discharged from the ED.

Pseudotumor Cerebri

A normal CT scan should be followed by LP to assess

opening pressure. An opening pressure >25 em H20 suggests the diagnosis. CSF should be removed to bring ICP

into the normal range (usually about 20 mL of CSF). Oral

acetazolamide and steroids may be started in the ED after

consulting with a neurologist.

Carotid or Vertebral Artery Dissection

For patients with only pain and no neurologic signs

suggestive of CVA, head CT scan is often normal. CT

angiography of neck, MRI/MRA, or duplex ultrasound

may show the abnormality in the affected vessel. Treatment

may include aspirin or heparin. Emergent neurologic and

vascular surgery consultation is appropriate.

DISPOSITION

� Admission

Most patients with an emergent secondary headache

should be admitted to the hospital. Patients with meningitis

with AMS, SAH, intracranial hemorrhage, cervical artery

dissection, or tumor with mass effect or signs of increased

ICP should be admitted to an intensive care unit.

� Discharge

Patients with benign headache syndromes whose pain is

well controlled can be discharged home. Patients with sec ­

ondary headaches that are not life- or organ-threatening

(temporal arteritis, pseudotumor cerebri) can be discharged home after close follow-up is arranged. These

patients should be given very specific instructions to

return if headache worsens or they experience any new or

different symptoms, including focal weakness, numbness,

speech or visual problems, or vomiting.

SUGGESTED READING

Denny CJ, Schull MJ. Headache and facial pain. In: Tintinalli JE,

Stapczynski JS, Ma OJ, Clince DM, Cydulka, RK, Meckler GD.

Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th

ed. New York, NY: McGraw-Hill, 201 1, pp. 1 1 13-11 18.

Edlow JA, Panagos PD, Godwin SA, et a!. Clinical policy: Critical

issues in the evaluation and management of adult patients

presenting to the emergency department with acute headache. Ann Emerg Med. 2008;52:407-436.

Swadron SP. Pitfalls in the management of headache in the

emergency department. Emerg Med Clin North Am.

20 1 0;28:127-147.

Dizziness

Wi lliam B. Lauth, MD

Key Points

• The patient's definition of "dizzi ness" must be clarified

with a careful and explicit history taken by the health

care provider.

• True vertigo must be differentiated from other types of

dizziness.

INTRODUCTION

Dizziness is one of the most common emergency department (ED) presentations and one of the most difficult to

characterize. Dizziness means different things to different

people and crosses language and cultural boundaries. The

precise definition ranges from weakness, giddiness, and

anxiety to true vertigo, presyncope, disequilibrium, or

nonspecific lightheadedness. A very careful history from

the patient, friends, or family is the most important part of

the initial evaluation of the dizzy patient.

Dizziness can be divided into 4 main types: vertigo,

presyncope, disequilibrium, and lightheadedness. Vertigo is

defined as the perception of movement where no move ­

ment exists. Patients often describe feeling the room spinning. It can be further divided into central and peripheral

types. Peripheral vertigo is usually benign and caused by an

inner ear problem, whereas central vertigo is usually serious

and involves pathology within the cerebellum or brainstem.

Presyncope is defined as lightheadedness derived from feeling an impending loss of consciousness. Disequilibrium

refers to a feeling of unsteadiness, imbalance, or a sensation

of floating while walking. Lightheadedness is the most difficult type of dizziness to characterize. Many patients in this

group have vague, poorly defined symptoms, such as j ust

not feeling right, that do not fall into one of the other

categories.

341

• Attempt to distinguish peripheral from central vertigo.

• Consider life-th reatening causes of dizzi ness such as

cardiac syncope and cerebellar infarct or hemorrhage

in all patients, especially the elderly.

The central nervous system (CNS) coordinates and

interprets sensory inputs from visual, vestibular, and proprioceptive systems. These 3 systems give us the sense of

position in our 3-dimensional universe. The disruption of

any 1 of these 3 can produce vertigo. The most common

forms of vertigo involve dysfunction of the vestibular apparatus and are thus considered peripheral vertigo. By far the

most common cause of vertigo is benign paroxysmal positional vertigo (BPPV), which is caused by a mechanical

disorder of the inner ear. It is due to the accumulation of

floating calcium carbonate particles in either the left or

right semicircular canals. These particles stimulate the labyrinth, causing asymmetric input from the normal and

affected semicircular canals, which produces the sensation

of vertigo. Clinically, BPPV is characterized by vertigo pre ­

cipitated by certain head movements, which aggravate this

unilateral dysfunction. Other causes of peripheral vertigo

include Meniere disease, labyrinthitis, and vestibular neu ­

ronitis. Meniere disease is a disorder in which there is an

increase in volume and pressure of the endolymph of the

inner ear, eventually leading to damage of the endolymphatic system and deafness. The pathophysiology of labyrinthitis is not completely understood, although many cases

are associated with systemic or viral illnesses, which is

thought to cause inflammation in the vestibular apparatus.

Viral infection of the vestibular nerve is believed to be the

most common cause of vestibular neuronitis.

CHAPTER 81

Central vertigo is much less common than peripheral

vertigo and is due to CNS dysfunction. Cerebellar infarct

or hemorrhage, cerebellopontine angle tumors and

schwannomas, and vertebrobasilar insufficiency frequently

cause central vertigo symptoms.

CLINICAL PRESENTATION

� History

The cause of dizziness can be elicited by history alone in

more than half of all cases. Patients with vertigo complain

of a sensation of movement, or "the room spinning"

around them, with associated nausea and vomiting. BPPV

usually has an abrupt onset, lasts < 1 minute, and is pro ­

voked by head movement. ED physicians should be aware

that some causes of central vertigo such as vertebrobasilar

insufficiency (VBI), transient ischemic attack, and cerebellar hemorrhage may also have an acute onset. Meniere

disease is associated with hearing loss and tinnitus, and the

vertigo usually lasts for hours. The vertigo caused by labyrinthitis and vestibular neuronitis usually lasts for a few

days. In contradistinction, the symptoms of central vertigo

are usually less acute, more persistent, and may have asso ­

ciated neurologic symptoms ( Table 81-1).

Patients with presyncope often complain of feeling as

though they are going to pass out. This may be associated

with a stressful event (vasovagal episode), exertion (aortic

stenosis), sudden change in posture (hypovolemia), or

Table 81-1. Differentiating peripheral

from central vertigo.

Peripheral

Onset Sudden

Severity of vertigo Intense spinning

Pattern Paroxysmal, intermittent

Aggravated by Yes

position/movement

Associated nausea/ Frequent

diaphoresis

Nystagmus Rotatory-vertical, horizontal

Fatigue of Yes

symptoms/signs

Hearing loss/tinnitus May occur

Abnormal tympanic May occur

membrane

Central nervous system Absent

symptoms/sign

Central

Sudden or slow

Ill-defined, less

intense

Constant

variable

variable

Vertical

No

Does not occur

Does not occur

Usually present

Reprinted with permission from Goldman B. Chapter 1 64. Vertigo and

Dizziness. In: Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK,

Meckler GO, eds. Tintina/lis Emergency Medicine: A Comprehensive

Study Guide. 7th ed. New York: McGraw-Hill, 201 1.

palpitations (dysrhythmia). Disequilibrium is most often a

complaint of elderly patients. Their sense of loss of balance

is usually worse at night (limited visual acuity is further

impaired) and later in the day (more fatigued). Patients

with lightheadedness usually have vague complaints. Past

medical history and associated chronic medical conditions

should be ascertained in an attempt to find a cause for

their complaints.

� Physical Examination

A complete physical examination should be performed,

paying special attention to a few key areas. Vital signs can

suggest a cause early in the evaluation. Hypotension suggests causes related to decreased cerebral perfusion,

whereas hypertension may point to VBI, stroke, or hemorrhage. Bradycardia or tachycardia may cause presyncope

from impaired cardiac output.

The head, eyes, ears, nose, and throat examination may

reveal a possible cause for vertigo. Ears should be carefully

examined for presence of a ruptured tympanic membrane,

decreased hearing, infection, cerumen impaction, and foreign bodies. The cardiovascular examination should assess

for signs of vascular insufficiency (carotid bruits, decreased

peripheral pulses). Auscultate for any arrhythmia or the

systolic murmur of aortic stenosis.

A complete neurologic examination is essential for all

patients with a complaint of dizziness. Assess for the presence and type of nystagmus. While performing the cranial

nerve examination, pay special attention to cranial nerves

VII, VIII, and IX. Cranial neuropathies associated with eranial nerve VIII suggest brainstem involvement and a central

cause of vertigo. Patients with peripheral vertigo should be

able to ambulate, although they may veer to one side.

Patients with cerebellar infarction or hemorrhage usually

cannot ambulate. A Romberg test can be used to differentiate cerebellar from spinal cord (posterior column) dysfunction. Have the patient stand, with feet together, and then

have them close their eyes. Excessive swaying or imbalance is

a positive test and is seen in patients with significant proprioceptive loss from posterior column dysfunction.

DIAGNOSTIC STUDIES

� Laboratory

No specific laboratory test can aid in the diagnosis of vertigo (Table 81-2). However, older patients on multiple

medications with nonspecific symptoms should have

hemoglobin, electrolytes, and renal function evaluated.

Electrocardiogram (ECG) and serial troponins should be

performed in patients suspected of having a cardiac cause

for their symptoms.

� Imaging

Head computed tomography (CT) scan is indicated in

patients with a suspected central cause for their symptoms

(focal neurologic findings, altered mental status, severe

Table 81-2. Anci llary testing of vertigo and dizziness.

Condition Suggested Tests

Bacterial labyrinthitis CBC, blood cultures, a scan or MRI for

possible abscess, lumbar puncture if

meningitis suspected

Vertigo associated with a scan or MRI

closed head injury

Near-syncope ECG, Holter monitor, CBC, glucose, electrolytes, renal function, table tilt testing

Cardiac dysrhythmias ECG, Holter monitor

Suspected valvular heart ECG, echocardiography

disease

Nonspecific diuiness; CBC, electrolytes, glucose, renal function

disequil ibrium of aging tests

Thyrotoxicosis

Cerebellar hemorrhage,

infarction or tumor

Vertebral artery

dissection

Vertebrobasilar

insufficiency

Thyroid stimulating hormone, triiodothyronine, thyroxine

a or MRI

Cerebral angiogram to include neck

vessels or MRA

ECG, cardiac monitoring, echocardiogram,

carotid Doppler, MRI, MRA

CBC, complete blood count.

Repri nted with permission from Goldman B. Chapter 1 64. Vertigo

and Dizziness. In: Tintina lli JE, Stapczynski JS, Cline OM, Ma OJ, Cydulka

RK, Meckler GO, eds. Tintinolli's Emergency Medicine: A

Comprehensive Study Guide. 7th ed. New York: McGraw-Hill, 201 1.

headache), or significant cerebrovascular accident risk factors (Figure 81-1). Magnetic resonance imaging (MRI)/

magnetic resonance angiography (MRA) may be per ­

formed if vertebral artery dissection or vertebrobasilar

insufficiency is considered.