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									CME Neurology                                                                                  Clinical Medicine 2010, Vol 10, No 4: 402–5

The bedside assessment of vertigo                                                                     ysmal positional vertigo (BPPV) often
                                                                                                      report that their dizziness lasted ‘a few min-
                                                                                                      utes’. It is worthwhile counting out aloud
                                                                                                      ‘1...2...3...’ and asking the patient to say ‘stop’
Diego Kaski, clinical research fellow;               lower limb incoordination or
Barry M Seemungal, clinician scientist                                                                when the recalled duration of intense spin-
and consultant neurologist,                                                                           ning dizziness has ended. Patients who
                                               •     Complaints of ‘giddiness’or ‘light-head-
                                                                                                      describe the attacks as lasting ‘minutes’ will
Department of Neuro-otology, Imperial                edness’ may suggest non-vestibular
College London, Charing Cross Hospital                                                                frequently say ‘stop’ after a few seconds.
                                                     causes such as anaemia, hypoglycaemia
                                                                                                      Patients with BPPV feel unsteady and dizzy
                                                     or orthostatic hypotension.
                                                                                                      (usually of the ‘rocking’ type) for several
Vertigo, an illusory sensation of self or
                                                                                                      minutes or hours after an acute attack.
environmental rotation is a common pre-
                                               Duration and time course
sentation to the emergency department,
                                               of vertigo                                             Physical examination
affecting approximately 20–30% of the
general population.1 Despite its frequency,    Subjective recall of time is inaccurate, par-          The core examination in patients in our
most clinicians find acute vertigo chal-       ticularly when episodes are brief (seconds             institution with vertigo and/or balance
lenging. An easy way of approaching it is to   to minutes). Patients with benign parox-               disorders is shown in Table 1.
have in mind the most common causes
and to consider them all during history        Table 1. Core examination of patients with vertigo and/or balance disorders.
taking and examination. When acute ver-
                                                   Eye movements                                   • Spontaneous nystagmus
tigo presents with other symptoms, the
diagnosis is easy, for example with facial                                                         • Effect of gaze direction on nystagmus
numbness in stroke or auditory distortion                                                          • Head impulse test
in Ménière’s. This discussion will therefore       Limb coordination
focus on the clinical approach to patients         Hallpike manoeuvre
presenting with acute isolated vertigo.            Gait assessment                                 • Romberg test
                                                                                                   • Tandem walking
History taking                                     Otoscope
                                                   (exclude Varicella Zoster Virus vesicles)
What is ‘vertigo’?                                 Clinical assessment of hearing

The vestibular organ detects head
motion, so abnormal activity in the
vestibular nerves may be interpreted by
the brain as self-motion. Lesions in the
brainstem may also affect these vestibular
signals, thus central lesions such as cere-
bellar strokes can also cause profound
vertigo. Nausea, vomiting and malaise
often accompany vertigo since there are
connections between the vestibular nuclei
and brainstem centres mediating nausea
and vomiting. It should be noted that the
presence or absence of nausea does not
reliably distinguish between a central or
peripheral lesion.
   Patients often use the term ‘dizziness’
to describe a variety of subjective sensa-
tions. Clarification of the terminology is
required to avoid diagnostic mistakes:

•   If the patient finds it difficult to
    explain their sensation, offer words
    like ‘merry-go-round’ (vertigo),
    rocking like a boat (not vertigo).         Fig 1. Unidirectional vestibular nystagmus (eg as in a left vestibular neuritis). The
•   A feeling of ‘unsteadiness’ without        figure shows the effect of gaze direction on a unilateral ve
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