31 y/o M presents with acute onset dizziness w/ nausea and vomiting. Sx started suddenly yesterday PM w/ dizziness described as “sensation of room spinning around me” that lasted for approximately 15 min, a/w nausea and mild bifrontal headache (similar to headaches he has had in the past) and flashes of light.
He had another episode early this AM w/ room spinning sensation that has continued since w/ severe nausea and multiple episodes of NBNB emesis. He is dizzy now. His HA has gradually increased in intensity to 7/10. He also now complains of R neck pain. The dizziness is worsened by head movements and standing.
Patient denies tinnitus/hearing change, f/c or recent illness. Denies weakness or numbness. Denies visual changes at this time. No family or personal history of migraines, ROS otherwise negative.
PMH / PSH
Social: lives w/ wife, no tobacco, social EtOH, occasional marijuana
BP 134/87, P 84, RR 18, SpO2 100%, on RA T 97.6, FS 110
Gen: moderate distress 2/2 nausea and vomiting
HEENT: PERRLA, EOMI w/ L gaze nystagmus, nl oropharynx
CV: RRR NRGM
Abdomen: soft nt/nd
Ext: wwp, moving all 4
Neuro: CN2-12 intact to exam; SILT, 5/5 strength and 3+ DTRs throughout extremities; symmetric finger tapping bilaterally, normal heel-to-shin, slight dysmetria with finger-nose-finger on right; broad based gait, falls to right on tandem walk; negative rhomberg.
Is this a central or peripheral lesion? Can you tell for sure based on the above information?
The patient’s symptoms (acute onset of a continuous vertiginous “room spinning” sensation) define acute vestibular syndrome, which can have either a peripheral of central cause. Either type of lesion can cause gait instability and can worsen with head motion, so we cannot differentiate a central or peripheral cause based on the above presentation.
What physical exam maneuvers could help you differentiate central/peripheral? How do you apply and interpret them?
The HINTS exam is a set of exam maneuvers that can differentiate peripheral and central causes of acute vestibular syndrome (the patient must be actively vertiginous during the exam). It is composed of Head Impulse, Nystagums, and Test of Skew. Findings from each maneuver can correspond to either a peripheral or central lesion. Any single central finding constitutes a central result. In their initial landmark study, Kattah et al found the HINTS exam 100% sensitive and 96% specific for a central cause of AVS (Kattah et al, 2009).
This EMCrit post includes the relevant primary literature, video examples of central and peripheral findings and other resources.
What imaging would you like next?
In this case the HINTS exam revealed no corrective saccade on head impulse, unidirectional nystagmus, and vertical skew deviation, consistent with a central cause of AVS. CTA head and neck, followed by traditional angiography, showed a right-sided vertebral artery dissection with 70% luminal narrowing as well as a left-sided dissection with 30% narrowing. An MRI and/or MRA would also have been appropriate tests, but were not done during the initial workup.
On further history the patient admitted to frequent yoga and stretching, and had “cracked his neck” immediately prior to symptom onset. He was discharged on aspirin and underwent outpatient workup for connective tissue disorders and possible stenting at an outside hospital.
- Kattah et al. HINTS to Diagnose Stroke in the Acute Vestibular Syndrome: Three-Step Bedside Oculomotor Examination More Sensitive than Early MRI Diffusion Weighted Imaging. Stroke, 2009;40;3504-3510.
- Weingart, Scott. EMCrit Podcast 33 – Diagnosis of Posterior Stroke. October 9, 2010. Accessed October 25, 2016. http://emcrit.org/podcasts/posterior-stroke/