What is the workup and plan for a 25-year-old male presenting to the Emergency Room (ER) with persistent dizziness for 2 weeks, without nystagmus?

From the Guidelines

The patient's workup and plan should focus on identifying the underlying cause of dizziness, with a low threshold for imaging given the absence of nystagmus.

Initial Evaluation

• A thorough clinical evaluation is essential to differentiate between various causes of dizziness, including benign paroxysmal positional vertigo (BPPV), central paroxysmal positional vertigo (CPPV), and other conditions such as vestibular migraine or autonomic dysfunction 1.
• The patient's symptoms and medical history should be carefully reviewed to identify any potential underlying conditions that may be contributing to the dizziness.

Diagnostic Testing

• Imaging may be necessary to rule out central causes of vertigo, such as mass lesions, hemorrhage, infarct, or demyelinating disease, especially in the absence of nystagmus or atypical features 1.
• MRI may be more useful than CT in detecting abnormalities, particularly in patients with persistent dizziness or atypical features, with a diagnostic yield of 4% for MRI DWI 1.
• Bedside tests, such as the Dix-Hallpike maneuver, can help differentiate between BPPV and CPPV, and guide further evaluation and management 1.

Management

• Treatment should be tailored to the underlying cause of dizziness, and may include vestibular rehabilitation, medications to manage symptoms, or surgical intervention in some cases.
• Patients with isolated dizziness and no underlying conditions may not require imaging, but should be closely monitored for any changes in symptoms or development of new symptoms 1.

From the Research

Initial Assessment

The patient, a 25-year-old male, presents to the Emergency Room (ER) with persistent dizziness for 2 weeks without nystagmus. The initial assessment should focus on the timing and triggers of the dizziness to develop a differential diagnosis 2.

Differential Diagnosis

The differential diagnosis for dizziness is broad and includes peripheral and central causes. Peripheral etiologies can cause significant morbidity but are generally less concerning, whereas central etiologies are more urgent 2. The most frequent disorders associated with dizziness are benign paroxysmal positional vertigo (22%) and stroke (20%) 3.

Physical Examination

The physical examination may include:

• Orthostatic blood pressure measurement
• A full cardiac and neurologic examination
• Assessment for nystagmus
• The Dix-Hallpike maneuver (for patients with triggered dizziness)
• The HINTS (head-impulse, nystagmus, test of skew) examination when indicated 2, 4

Laboratory Testing and Imaging

Laboratory testing and imaging are usually not required but can be helpful. The usefulness of brain imaging studies in dizzy patients presenting to the emergency department is controversial 5.

Treatment

The treatment for dizziness is dependent on the etiology of the symptoms. Canalith repositioning procedures (e.g., Epley maneuver) are the most helpful in treating benign paroxysmal positional vertigo. Vestibular rehabilitation is helpful in treating many peripheral and central etiologies 2.

Key Considerations

• Emergency clinicians should receive training in bedside physical examination techniques for patients with the acute vestibular syndrome (AVS; HINTS) and the diagnostic and therapeutic maneuvers for benign paroxysmal positional vertigo (BPPV; Dix-Hallpike test and Epley maneuver) 4
• The risk of acute brain lesions (ABLs) increases with the presence of central oculomotor signs or focal abnormalities 5
• Patients with HINTS-negative acute vestibular syndrome should not receive brain imaging, whereas imaging is suggested in dizzy patients with acute imbalance, central oculomotor signs, or focal abnormalities 5

Diagnostic Approach

The diagnostic approach may involve:

• Considering the most relevant differential diagnoses and dangerous aetiologies that require immediate action 6
• Using the three-component HINTS Test to distinguish central from peripheral causes of the acute vestibular syndrome 6
• Searching for symptoms or signs of cerebral ischemia in patients with spontaneous episodic vestibular syndrome 4