Consensus paper on the management of acute isolated vertigo in the emergency department

Abstract

Acute vertigo is defined as the perception of movement of oneself or the surroundings in the absence of actual motion and it is a frequent cause for emergency department admissions. The utilization of medical resources and the duration of hospital stay for this kind of symptom is high. Furthermore, the efficiency of brain imaging in the acute phase is low, considering the limited sensitivity of both CT and MRI for diagnosing diseases that are the causes of central type of vertigo. Relying on imaging tests can provide false reassurance in the event of negative results or prolong the in-hospital work-up improperly. On the other hand, clinical examinations, notably the assessment of nystagmus' features, have proven to be highly accurate and efficient when performed by experts. Literature data point out that emergency physicians often do not employ these skills or use them incorrectly. Several clinical algorithms have been introduced in recent years with the aim of enhancing the diagnostic accuracy of emergency physicians when evaluating this specific pathology. Both the 'HINTS and 'STANDING' algorithms have undergone external validation in emergency physician hands, showing good diagnostic accuracy. The objective of this consensus document is to provide scientific evidence supporting the clinical decisions made by physicians assessing adult patients with acute vertigo in the emergency department, particularly in cases without clear associated neurological signs. The document aims to offer a straightforward and multidisciplinary approach. At the same time, it tries to delineate benchmarks for the formulation of local diagnostic and therapeutic pathways, as well as provide a base for the development of training and research initiatives.

Keywords: Acute peripheral vestibular dysfunction; Benign paroxysmal positional vertigo; Dizziness; Emergency Medicine; HINTS; Ischemic stroke; Nystagmus; STANDING; Vertigo.

Fig. 1

Essential steps of clinical evaluation

Fig. 2

Techniques for detecting nystagmus without fixation

Fig. 3

HIT [Head Impulse Test] A negative HIT, normal function of the right lateral canal: suspected central disease. B positive HIT, probable peripheral pathology due to right APVD

Fig. 4

The right Dix-Hallpike maneuver. The patient begins in a seated position with legs on the table. The examiner gradually rotates the patient's head approximately 45° to the right and quickly transitions him to a supine position, with the head hyperextended out of the table. In cases of significant dorsal spine kyphosis, commonly observed in older patients, simple supine positioning achieves the desired hyperextension of the head. The left Dix-Hallpike maneuver mirrors the aforementioned procedure. [PSC: Posterior Semicircular Canal, A: plane of the anterior canal, P: plane of the posterior canal L: plane of the lateral canal, U: utricle, C: dome]

Fig. 5

BPPV-LSC in geotropic form. The figure presents head positions at the top and the corresponding excursion of otoconial debris at the bottom. Arrows above denote the direction and intensity of nystagmus, while below indicate the amplitude of debris movement. a The patient in a supine position with a stable head exhibits an absence of nystagmus. b Upon a 90° rotation of the head to the left, there is an ampullipetal movement of otoconial debris, resulting in a moderately intense left geotropic nystagmus. c A 180° rotation of the head to the right induces a larger, ampullifugal movement of inhibitory otoconial debris, accompanied by a right geotropic nystagmus of medium intensity. d A 180° movement of the head to the left leads to a broader excursion of otoconial debris in the ampullipetal direction, causing a vigorous left geotropic nystagmus

Fig. 6

STANDING algorithm. HIT: Head Impulse Test; APVD: Acute Peripheral Vestibular Dysfunction: BPPV: Benign Paroxysmal Peripheral Vertigo

Fig. 7

Upper panel: acute vertigo. A NCCT examination upon emergency department admission. B NCCT examination at 24 h from admission, revealing the emergence of a hypodense area indicative of acute vascular ischemia in the left cerebellar hemisphere. C NCCT examination upon emergency department admission. D MRI examination with Diffusion-Weighted Imaging [DWI] sequence at 72 h from admission, illustrating the presence of a diffusion restriction area suggestive of a recent vascular ischemic lesion in the right cerebellar hemisphere. Lower Panel: acute vertigo. A Baseline CT examination upon emergency department admission. B Baseline CT examination at 24 h from admission, demonstrating hypodensity in the right cerebellar hemisphere. C and D MRI examination with Fluid-Attenuated Inversion Recovery [FLAIR] sequence revealing hyperintensity in the territory of the right Posterior Inferior Cerebellar Artery [PICA]

Fig. 8

Epley Maneuver for BPPV of the left PSC A initiates the Epley maneuver from a seated position by turning the head 45° to the affected side [left] and progressing to the Dix-Hallpike left position. B Continue the rotation until reaching the Dix-Hallpike right position. C Subsequently, turn the patient until the face is directed downwards. D Conclude the maneuver by bringing the patient back to a sitting position [E]. Execute each step slowly, incorporating pauses of 30"—60". F Semont Maneuver for BPPV of the left PSC. Letters A, B, C, and D inside the Fig indicate the sequential phases of the Semont maneuver

Fig. 9

Multi-professional pathway of the patient with acute isolated vertigo in ED