What is the management approach for patients with a high Sudbury vertigo risk score (SVRS)?

Management of Patients with High Sudbury Vertigo Risk Score (SVRS)

Patients with a high Sudbury Vertigo Risk Score (>8) should receive urgent neuroimaging, preferably MRI brain without contrast, and neurological consultation due to their 41% risk of serious underlying pathology.

Understanding the Sudbury Vertigo Risk Score

The Sudbury Vertigo Risk Score (SVRS) is a validated clinical prediction tool that helps stratify patients presenting with vertigo according to their risk of having a serious underlying cause, such as stroke, transient ischemic attack, vertebral artery dissection, or brain tumor 1, 2.

The 7-item SVRS includes:

• Male gender
• Age over 65
• Hypertension
• Diabetes
• Motor/sensory deficits
• Cerebellar signs/symptoms
• Absence of BPPV diagnosis

Risk stratification based on SVRS:

• Score <5: 0% risk of serious diagnosis
• Score 5-8: 2.1% risk of serious diagnosis
• Score >8: 41% risk of serious diagnosis

Management Algorithm for High SVRS Patients

Immediate Actions

1. Neuroimaging: Order MRI brain without contrast as the preferred imaging modality 3

   • If MRI is unavailable or contraindicated, CT head may be used, though it has lower sensitivity for posterior fossa lesions
   • If subarachnoid hemorrhage is suspected and CT is negative, proceed to lumbar puncture 3

2. Neurological Consultation: Obtain urgent neurological evaluation for patients with SVRS >8

3. Vital Signs Monitoring: Monitor blood pressure, heart rate, oxygen saturation, and neurological status

Additional Assessment

1. Focused Vestibular Examination:

   • HINTS examination (Head Impulse, Nystagmus, Test of Skew) to differentiate central from peripheral causes 3
   • Look specifically for:
     • Direction-changing nystagmus
     • Downbeating nystagmus
     • Nystagmus that doesn't suppress with visual fixation
     • Skew deviation
     • Abnormal head impulse test

2. Laboratory Testing:

   • Complete blood count
   • Basic metabolic panel
   • Blood glucose
   • Thyroid function tests 3

3. Fall Risk Assessment:

   • Evaluate using validated tools such as:
     • Activities-Specific Balance Confidence Scale
     • Dizziness Handicap Inventory
     • Dynamic Gait Index
     • Timed Up & Go test 3

Management Based on Diagnosis

If Central Cause Confirmed

1. Stroke Management: If stroke is diagnosed, initiate appropriate stroke protocols

   • Consider thrombolysis if within time window
   • Neurosurgical consultation for space-occupying lesions

2. Vestibular Rehabilitation: Initiate early vestibular rehabilitation therapy once patient is stable 4, 3

   • Individualized programs designed to activate central neuroplastic mechanisms
   • Focus on gaze stabilization, balance training, and gait exercises

3. Follow-up: Schedule reassessment within 1 month after initial treatment 3

If No Central Cause Identified Despite High SVRS

1. Close Monitoring: Arrange close follow-up within 1-2 weeks

2. Limited Course of Vestibular Suppressants: Consider for symptomatic relief only during acute vertigo attacks 4

   • Avoid long-term use as they can interfere with central compensation
   • Options include:
     • Benzodiazepines (short-term only due to risk of dependence)
     • Anticholinergics (scopolamine, glycopyrrolate)

3. Fall Prevention Strategies:

   • Home safety assessment
   • Assistive devices if needed
   • Supervision recommendations 3

Special Considerations

Elderly Patients

• Higher risk for falls with vertigo 4
• Conduct detailed falls risk assessment
• Consider questions recommended by CDC:
  • History of falls in past year
  • Feelings of unsteadiness when standing/walking
  • Concerns about falling 4

Patients with Comorbidities

• Patients with BPPV and underlying CNS disorders may still benefit from conventional BPPV treatments 4
• Posttraumatic BPPV may be more refractory and require repeated physical treatments 4
• Consider migraine prophylaxis in patients with recurrent vertigo and migraine history 3

Red Flags Requiring Immediate Attention

• Sudden severe headache with vertigo
• New or progressive neurological symptoms
• Inability to walk or stand
• Persistent vomiting with vertigo
• Altered mental status 3

Follow-up Protocol

1. Reassess within 1 month for treatment response
2. Use validated assessment tools to track progress
3. Consider additional interventions if symptoms persist
4. Document triggers, timing, and associated symptoms

By following this structured approach to managing patients with high SVRS, clinicians can ensure appropriate evaluation and treatment, potentially reducing morbidity and mortality associated with serious causes of vertigo.