What is the management approach for patients presenting with dizziness and suspected central causes?

Management of Dizziness with Suspected Central Causes

The management of patients with dizziness and suspected central causes should prioritize rapid neuroimaging with MRI brain (without contrast) for those with abnormal HINTS examination, neurological deficits, or high vascular risk factors, even with normal examination. 1, 2

Red Flags for Central Causes

• Age ≥65 years (OR=6.13) 3
• Ataxia symptoms (OR=11.39) 3
• Focal neurological symptoms (OR=11.78) 3
• History of previous stroke (OR=3.89) 3
• Diabetes mellitus (OR=3.57) 3
• Central oculomotor signs 4

Diagnostic Approach

1. Categorize the Dizziness Syndrome

• Acute Vestibular Syndrome (AVS): Acute persistent continuous dizziness lasting days to weeks with nausea, vomiting, and head motion intolerance 1
• Triggered Episodic Vestibular Syndrome: Episodic dizziness triggered by specific actions (e.g., BPPV) 1
• Spontaneous Episodic Vestibular Syndrome: Untriggered episodic dizziness lasting minutes to hours 1
• Chronic Vestibular Syndrome: Dizziness lasting weeks to months or longer 1

2. Perform HINTS Examination for AVS

• Head-Impulse Test: Abnormal (peripheral) = corrective saccade; Normal (central) = no corrective saccade
• Nystagmus: Unidirectional horizontal (peripheral) vs bidirectional or vertical/torsional (central)
• Test of Skew: Present (central) vs absent (peripheral)

When performed by specially trained practitioners, HINTS is more sensitive than early MRI for detecting stroke (100% versus 46%) 1

3. Neuroimaging Decision Algorithm

• Immediate MRI brain indicated for:

  • AVS with abnormal HINTS examination
  • AVS with neurological deficits
  • High vascular risk patients with AVS even with normal examination
  • Acute imbalance syndrome with ABCD2 score ≥4 (50% risk of acute brain lesions) 4

• CT head without contrast may be considered when MRI is unavailable, but has low sensitivity (20-40%) for posterior fossa lesions 1

• No imaging needed for:

  • HINTS-negative acute vestibular syndrome (0% risk of acute brain lesions) 4
  • Clear peripheral causes like BPPV with positive Dix-Hallpike test and no neurological deficits

Central Causes to Consider

1. Posterior circulation stroke/TIA (25% of AVS cases, up to 75% in high vascular risk cohorts) 1
2. Multiple sclerosis (4% of AVS cases, usually with additional neurological findings) 1
3. Cerebellar hemorrhage 1
4. Posterior fossa tumors 2
5. Central paroxysmal positional vertigo 1
6. Demyelinating diseases 1

Management Steps

1. Stabilize the patient if acutely ill (IV fluids, antiemetics as needed)

2. For confirmed stroke:

   • Initiate stroke protocol and management per current guidelines
   • Neurology consultation
   • Consider thrombolysis if within time window

3. For other central causes:

   • Consult appropriate specialist (neurology, neurosurgery)
   • Targeted treatment based on etiology

4. Vestibular rehabilitation for persistent symptoms after acute management 5

Common Pitfalls to Avoid

• Relying solely on symptom quality rather than timing and triggers 6, 5
• Overreliance on CT imaging which has poor sensitivity for posterior fossa lesions 1
• Missing stroke in isolated AVS - 11% of patients with acute persistent vertigo but no focal neurologic symptoms have acute infarct on imaging 1
• Overuse of vestibular suppressants which can delay central compensation 2, 5
• Failure to recognize that 75-80% of patients with AVS related to infarct have no associated focal neurologic deficits 1

Remember that the prevalence of cerebrovascular disease in patients presenting with AVS is approximately 25% and may be as high as 75% in high vascular risk cohorts 1, making appropriate evaluation and management critical for preventing morbidity and mortality.