1. What elements of history do you find most reliable in differentiating central from peripheral vertigo?
2. What elements of physical exam do you find most reliable in differentiating central from peripheral vertigo?
3. When do you obtain imaging in a patient with vertigo? Which study do you use and why?
4. In which, if any, patients do you perform a Dix-Hallpike maneuver? In which patients do you perform an Epley maneuver?
Over 50 and can’t stand without listing to one side I will get mri to rule out cerebellar cva. Gait disturbance and diplopia are two associated findings for dizziness that I will add imaging to the workup
1) Timing first: assess whether symptom is intermittent or continuos. Longlasting (>24) with no symptom gap should lead to investigate the presence of telltale signs (acute vestibular syndrome workup). Intermittent dizziness should prompt looking for triggers in order to discern positional paroxysmal vertigo from episodic vestibular syndromes.
No prepackaged classification based on patients reffered quality of symptoms.
Ascertain presence of any cervical pain or headache and if multiple prior prodromic events.
2) Any presumed new neurodeficit.
Rest and gaze evocked nystamus: direction changing nystamus suggestive for central cause.
Skew deviation (ocular vertical misalignment).
Head impulse test.
3)weight diffusion MRI for all acute vestibular syndromes or episodic syndromes with symptoms present at visit time showing an abnormal HINTS battery. MRI also for pt. with undetermined HINTS battery above 60y or with high cardiovascular risk or with neck pain/headache.
No CT scan: too low sensitivity.
4) Dix-Hallpike maneuver and Roll test in all intermittent dizziness with triggers. Modified Epley for all patients with positive Dix-Hallpike maneuver.