Central Vertigo Treatment & Management

  • Author: Keith A Marill, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP   more...
 
Updated: Jan 21, 2011
 

Emergency Department Care

First, distinguish true vertigo from disequilibrium and other forms of dizziness. Ascertaining this history from patients sometimes requires patience and persistence. Once the presence of vertigo or disequilibrium has been confirmed, consider a central cause. Evaluate on the basis of a careful history and physical examination and liberal use of imaging studies of the posterior fossa.

  • Therapy usually targets the etiology of the symptoms. However, a variety of medications may be used to reduce symptoms of central vertigo, including antihistamines and benzodiazepines.
  • Regardless of the vertigo's etiology, attempt to alleviate the patient's suffering.
    • Place intravenous lines to rehydrate patients.
    • Allow patients to lie still in bed as desired.
    • Administer parenteral medicines for symptomatic relief.
  • If clinical and radiologic evaluation suggest an acute ischemic stroke, consider thrombolytic therapy after thorough evaluation and consultation.
    • Thrombolytic therapy is administered with an intra-arterial catheter close to the clot[14] , or intravenously, if within 3 hours of the onset of symptoms and no other contraindications exist.[15]
    • Prior to using thrombolytic therapy, consider several issues, especially the risk of intracerebral bleeding. Emergency physicians should be familiar with contraindications such as major surgery within the previous 10 days, severe hypertension, evidence of acute bleed or edema on CT scan, and rapidly improving symptoms.
    • The decision to administer thrombolytic therapy preferably is made with direct neurologic consultation and only after the patient has received a thorough explanation of the procedure and given informed consent. This therapy is discussed further in other articles (see Stroke, Ischemic and Thrombolytic Therapy).
  • Lethargic patients or those with altered level of consciousness require vigilance and close supervision, including direct visual, ECG, and pulse oximetry monitoring.
  • Do not administer anticoagulant medicine, including aspirin, until intracranial hemorrhage has been ruled out by imaging.
  • Imaging studies should be performed expeditiously, and the patient never should be left unattended by clinical personnel in the imaging suite.
  • Patients with altered consciousness and a deteriorating course in the ED may require emergent interventions to minimize edema and brainstem compression.
    • As the posterior fossa is a relatively small and nonexpandable space, hemorrhage or edema can lead to rapid compression and compromise of vital medullary functions, obstructive hydrocephalus, or herniation of the medullary tonsils.
    • Invasive actions may include endotracheal intubation to protect the airway, control breathing, and allow therapeutic hyperventilation.
    • Consider elevating the head of the bed, performing diuresis with mannitol or furosemide, and administering dexamethasone.
  • Preliminary evidence suggests that recombinant activated factor VII may be useful for acute hemorrhagic stroke when administered within 4 hours of symptom onset.[16] The data supporting the use of this therapy for hemorrhagic cerebellar stroke is too limited thus far to make a therapeutic recommendation, but further results are expected to clarify its utility and adverse effect profile.
Next

Consultations

Obtain neurologic consultation for patients with central vertigo, and consider neurosurgical consultation for all patients with space-occupying lesions or hydrocephalus.

The emergency physician should seek immediate neurosurgical consultation for patients with hemorrhage, brainstem compression, or edema, as surgical decompression via suboccipital craniectomy or ventriculostomy may be lifesaving.

Previous
Proceed to Medication
 
 
Contributor Information and Disclosures
Author

Keith A Marill, MD  Faculty, Department of Emergency Medicine, Massachusetts General Hospital, Assistant Professor, Harvard Medical School

Keith A Marill, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine

Disclosure: Medtronic Ownership interest None; Cambridge Heart, Inc. Ownership interest None; General Electric Ownership interest None

Specialty Editor Board

Francis Counselman, MD  Program Director, Chair, Professor, Department of Emergency Medicine, Eastern Virginia Medical School

Francis Counselman, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Association of Academic Chairs of Emergency Medicine (AACEM), Norfolk Academy of Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

J Stephen Huff, MD  Associate Professor, Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health Sciences Center

J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP  Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References

  1. St. Louis EK, Wijdicks EF, Li H. Predicting neurologic deterioration in patients with cerebellar hematomas. Neurology. Nov 1998;51(5):1364-9. [Medline].

  2. Chen CC, Cheng PW, Tseng HM, Young YH. Posterior cranial fossa tumors in young adults. Laryngoscope. Sep 2006;116(9):1678-81. [Medline].

  3. Selesnick SH, Jackler RK, Pitts LW. The changing clinical presentation of acoustic tumors in the MRI era. Laryngoscope. Apr 1993;103(4 Pt 1):431-6. [Medline].

  4. Fitzgerald DC. Head trauma: hearing loss and dizziness. J Trauma. Mar 1996;40(3):488-96. [Medline].

  5. Amarenco P. The spectrum of cerebellar infarctions. Neurology. Jul 1991;41(7):973-9. [Medline].

  6. Lee H, Sohn SI, Cho YW, Lee SR, Ahn BH, Park BR. Cerebellar infarction presenting isolated vertigo: frequency and vascular topographical patterns. Neurology. Oct 10 2006;67(7):1178-83. [Medline].

  7. Kase CS, Norrving B, Levine SR. Cerebellar infarction - clinical and anatomic observations in 66 cases. Stroke. 1993;24 (1):76-83. [Medline].

  8. Hornig CR, Rust DS, Busse O, Jauss M, Laun A. Space-occupying cerebellar infarction. Clinical course and prognosis. Stroke. Feb 1994;25(2):372-4. [Medline].

  9. Drachman DA. A 69-year-old man with chronic dizziness. JAMA. Dec 23-30 1998;280(24):2111-8. [Medline].

  10. Newman-Toker DE, Kattah JC, Alvernia JE, Wang DZ. Normal head impulse test differentiates acute cerebellar strokes from vestibular neuritis. Neurology. Jun 10 2008;70(24 Pt 2):2378-85. [Medline].

  11. Norrving B, Magnusson M, Holtas S. Isolated acute vertigo in the elderly; vestibular or vascular disease?. Acta Neurol Scand. Jan 1995;91(1):43-8. [Medline].

  12. Ferbert A, Bruckmann H, Drummen R. Clinical features of proven basilar artery occlusion. Stroke. Aug 1990;21(8):1135-42. [Medline].

  13. Simmons Z, Biller J, Adams HP Jr, Dunn V, Jacoby CG. Cerebellar infarction: comparison of computed tomography and magnetic resonance imaging. Ann Neurol. Mar 1986;19(3):291-3. [Medline].

  14. Hacke W, Zeumer H, Ferbert A. Intra-arterial thrombolytic therapy improves outcome in patients with acute vertebrobasilar occlusive disease. Stroke. 1988;19 (10):1216-22. [Medline].

  15. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. Dec 14 1995;333(24):1581-7. [Medline].

  16. Mayer SA, Brun NC, Begtrup K, Broderick J, Davis S, Diringer MN, et al. Recombinant activated factor VII for acute intracerebral hemorrhage. N Engl J Med. Feb 2005;352:777-85. [Medline].

  17. Johnston SC, Rothwell PM, Nguyen-Huynh MN, Giles MF, Elkins JS, Bernstein AL, et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet. Jan 2007;369:283-92. [Medline].

  18. Kim AS, Fullerton HJ, Johnston SC. Risk of vascular events in emergency department patients discharged home with diagnosis of dizziness or vertigo. Ann Emerg Med. Jan 2011;57(1):34-41. [Medline].

  19. Anagnostou E, Varaki K, Anastasopoulos D. A minute demyelinating lesion causing acute positional vertigo. J Neurol Sci. Mar 15 2008;266(1-2):187-9. [Medline].

  20. Bradley WG. MR of the brain stem: a practical approach. Radiology. May 1991;179(2):319-32. [Medline].

  21. Bruzzone MG, Grisoli M, De Simone T, Regna-Gladin C. Neuroradiological features of vertigo. Neurol Sci. Mar 2004;25 Suppl 1:S20-3. [Medline].

  22. Delaney KA. Bedside diagnosis of vertigo: value of the history and neurological examination. Acad Emerg Med. Dec 2003;10(12):1388-95. [Medline].

  23. Froehling DA, Silverstein MD, Mohr DN. Does this dizzy patient have a serious form of vertigo?. JAMA. Feb 2 1994;271(5):385-8. [Medline].

  24. Gizzi M, Riley E, Molinari S. The diagnostic value of imaging the patient with dizziness. A Bayesian approach. Arch Neurol. Dec 1996;53(12):1299-304. [Medline].

  25. Herr RD, Zun L, Mathews JJ. A directed approach to the dizzy patient. Ann Emerg Med. Jun 1989;18(6):664-72. [Medline].

  26. Hotson JR, Baloh RW. Acute vestibular syndrome. N Engl J Med. Sep 3 1998;339(10):680-5. [Medline].

  27. Macdonell RA, Kalnins RM, Donnan GA. Cerebellar infarction: natural history, prognosis, and pathology. Stroke. 1987;18 (5):849-55. [Medline].

  28. [Best Evidence] Mayer SA, Brun NC, Begtrup K. Recombinant activated factor VII for acute intracerebral hemorrhage. N Engl J Med. Feb 2005;352(8):777-85. [Medline].

  29. Rother J, Wentz KU, Rautenberg W. Magnetic resonance angiography in vertebrobasilar ischemia. Stroke. 1993;24 (9):1310-15. [Medline].

  30. Sacco RL, Freddo L, Bello JA, Odel JG, Onesti ST, Mohr JP. Wallenberg's lateral medullary syndrome. Clinical-magnetic resonance imaging correlations. Arch Neurol. Jun 1993;50(6):609-14. [Medline].

  31. Solomon D. Distinguishing and treating causes of central vertigo. Otolaryngol Clin North Am. Jun 2000;33(3):579-601. [Medline].

 
Previous
Next
 
CT scan of a patient with an acute spontaneous cerebellar hemorrhage. The hemorrhage in the right lobe of the cerebellum is partly obscured by bony artifact.
MRI of a patient with an acute cerebellar hemorrhage less than 24 hours after presentation. MRI allows better resolution than CT scan without bony artifact. MRI is preferred over CT scan for imaging lesions in the posterior fossa.
CT scan of a patient with a large acoustic neuroma on the right side of the brainstem. The scan was performed after injection of intravenous contrast, which is critical for identifying tumors with CT imaging.
A CT slice through the brain of a patient with an acoustic neuroma. This slice reveals a level of the brain higher than the acoustic neuroma. The dilated third and lateral ventricles provide gross evidence of obstructive hydrocephalus due to pressure exerted by the tumor on the brainstem. A ventriculostomy, seen as a white circle in the right lateral ventricle, has been placed in an attempt to drain cerebrospinal fluid and relieve the excessive pressure above the brainstem.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.