Nice review. A caveat is how thorough and accurate was the history. If vertigo is the most distressing symptom other symptoms may not be asked about or reported by the patient or even if asked about not reported or report in such a way about in such a way that it is not picked up by the examiner. Vestibular/posterior circulation migraine should be a diagnosis of exclusion. Less than optimal histories may result in an incorrect impression that an episode is one of isolated vertigo when it isn’t, which may lead to missing serious disorders that require treatment including life and brain saving interventions. As a neurologist over the years I have come across cases that were mis-diagnosed as vestibular and posterior circulation migraines that resulted in significant morbidity and even mortality. These cases remind us of two important principles for clinicians: 1) The importance of the history 2) What may the patient’s differential diagnosis reasonably include that requires rapid intervention to prevent morbidly and mortality.
Excellent points. Vestibular migraine is definitely made by history, but so often overlooked by front line providers. When someone has a history of migraine headaches and has had many similar episodes of dizziness over a prologued period of time with periods of normality between the episodes, the chances of it being vestibular migraine is very high, and of it being a TIA is vanishing low. We obviously are looking at this problem from a different lens. The errors I see are the common benign problems being misdiagnosed as the rare and serious (even obvious cases) and you see the rare being misdiagnosed as the common. We would both like to see less of these errors. And I think it's possible to accomplish those goals, and as you state, the history is paramount. If you can confidently diagnose BPPV by bedside testing or recurrent vestibular migraine by a good history, then it it quite reasonable in my opinion to exclude TIA from the differential diagnosis.
Thank you professor Johns. This really helps me a lot. I also read those references from Dr. Edlow's paper. We need a time machine to go back to one or two weeks ago to check if those "isolated vertigo" are really isolated.
why we use the term posterior circulation for stroke and why we consider the cerebelleum for vertigo stroke? i mean there are real brain strokes as well which are more common than cerebellar one , so why we not consider the brain stroke if we talk about vertigo ?thank you
When patient present with isolated dizziness and no other neurologic symptoms, most patients will have a peripheral vestibular cause. Some will be having a stroke. I am not aware of any anterior circulation stroke that can present with isolated dizziness. But posterior circulation strokes can. Hope this answers your question.
I love your videos and your information presented on your website. I totally agree with you on patient dx'd with TIA that you found to actually be BPPV of the PC, however, the dissociation of her eye movements concerned me. She seemed to yawn yet her right eye medially rotated and went superior and closed, and her left eye did not seem be yoked to it, moving is different directions. Your take?
People often describe the nystagmus in BPPV as simply rotational towards the downward ear. There is more to it than that. The nystagmus is both vertical upwards and rotational towards the downward ear. If the patient looks towards the upward ear, the nystagmus is more vertical. Towards the downward ear, it's more rotational. Baloh described how the vertical component is more in the upward eye, and the rotational component is more in the downward eye. If you want a longer answer, see this video ua-cam.com/video/Nroy9DLiOt4/v-deo.html
How many months does the vertigo usually last which is due to posterior circulation stroke? If we detect the central cause weeks later by MRI, should we still treat that stroke by any medication? As far as i know, some acute strokes may remain undetected at early stages.
I've always experienced extreme vertigo when doing any kind of roller coaster rides or even in a car and not driving. All my life. Last Thursday I suffered a TIA, no vertigo really, almost passed out, extreme weakness, couldn't even push the break pedal as I was driving at the time. The following days since TIA, 3 days now, I'm experiencing vertigo, especially from bright lights, quick turning of my head, TV shows that move camera around quickly, etc. Seems like coffee might be amplifying the situation but I'm not certain yet. This is quite miserable. I have an appointment scheduled to see my nurse practionier in a few days. I feel like I need to see a specialist or two. Should I look for a stroke specialist or a vertigo specialist or both? I'm in Northern California.
The most important thing is to see someone who has an interest in vertigo. Some neurologists and ENT don’t have much interest in it, and that’s not who you want to see.
Regarding psychiatric causes of vertigo, I don't see many. The ones I see are usually associated with panic symptoms such as "can't get enough air", shaky hands, paresthesia hands, rapid heart rate, dizziness, dry mouth and feelings of anxiety/panic. Metabolic induced dizziness such as hypoglycemia/electrolyte disorders, hyper and hypothyroidism usually have other features that might make you suspect it. They certainly wouldn't have the diagnostic features of BPPV/vestibular neuritis/vestibular migraine/posterior circulation stroke.
Nice review. A caveat is how thorough and accurate was the history. If vertigo is the most distressing symptom other symptoms may not be asked about or reported by the patient or even if asked about not reported or report in such a way about in such a way that it is not picked up by the examiner. Vestibular/posterior circulation migraine should be a diagnosis of exclusion. Less than optimal histories may result in an incorrect impression that an episode is one of isolated vertigo when it isn’t, which may lead to missing serious disorders that require treatment including life and brain saving interventions. As a neurologist over the years I have come across cases that were mis-diagnosed as vestibular and posterior circulation migraines that resulted in significant morbidity and even mortality. These cases remind us of two important principles for clinicians:
1) The importance of the history 2) What may the patient’s differential diagnosis reasonably include that requires rapid intervention to prevent morbidly and mortality.
Excellent points. Vestibular migraine is definitely made by history, but so often overlooked by front line providers. When someone has a history of migraine headaches and has had many similar episodes of dizziness over a prologued period of time with periods of normality between the episodes, the chances of it being vestibular migraine is very high, and of it being a TIA is vanishing low.
We obviously are looking at this problem from a different lens. The errors I see are the common benign problems being misdiagnosed as the rare and serious (even obvious cases) and you see the rare being misdiagnosed as the common. We would both like to see less of these errors. And I think it's possible to accomplish those goals, and as you state, the history is paramount. If you can confidently diagnose BPPV by bedside testing or recurrent vestibular migraine by a good history, then it it quite reasonable in my opinion to exclude TIA from the differential diagnosis.
When you said deep dive, I didn't know it is going to be this deep! Awesome presentation
Thank you professor Johns. This really helps me a lot. I also read those references from Dr. Edlow's paper. We need a time machine to go back to one or two weeks ago to check if those "isolated vertigo" are really isolated.
Excellent, great work....
It was a great confusion that you solved... ❤️
why we use the term posterior circulation for stroke and why we consider the cerebelleum for vertigo stroke? i mean there are real brain strokes as well which are more common than cerebellar one , so why we not consider the brain stroke if we talk about vertigo ?thank you
When patient present with isolated dizziness and no other neurologic symptoms, most patients will have a peripheral vestibular cause. Some will be having a stroke. I am not aware of any anterior circulation stroke that can present with isolated dizziness. But posterior circulation strokes can. Hope this answers your question.
very nice video and very nice dog. thank you
I love your videos and your information presented on your website. I totally agree with you on patient dx'd with TIA that you found to actually be BPPV of the PC, however, the dissociation of her eye movements concerned me. She seemed to yawn yet her right eye medially rotated and went superior and closed, and her left eye did not seem be yoked to it, moving is different directions. Your take?
People often describe the nystagmus in BPPV as simply rotational towards the downward ear. There is more to it than that. The nystagmus is both vertical upwards and rotational towards the downward ear. If the patient looks towards the upward ear, the nystagmus is more vertical. Towards the downward ear, it's more rotational. Baloh described how the vertical component is more in the upward eye, and the rotational component is more in the downward eye. If you want a longer answer, see this video ua-cam.com/video/Nroy9DLiOt4/v-deo.html
How many months does the vertigo usually last which is due to posterior circulation stroke? If we detect the central cause weeks later by MRI, should we still treat that stroke by any medication? As far as i know, some acute strokes may remain undetected at early stages.
I've always experienced extreme vertigo when doing any kind of roller coaster rides or even in a car and not driving. All my life.
Last Thursday I suffered a TIA, no vertigo really, almost passed out, extreme weakness, couldn't even push the break pedal as I was driving at the time.
The following days since TIA, 3 days now, I'm experiencing vertigo, especially from bright lights, quick turning of my head, TV shows that move camera around quickly, etc. Seems like coffee might be amplifying the situation but I'm not certain yet.
This is quite miserable. I have an appointment scheduled to see my nurse practionier in a few days.
I feel like I need to see a specialist or two. Should I look for a stroke specialist or a vertigo specialist or both? I'm in Northern California.
The most important thing is to see someone who has an interest in vertigo. Some neurologists and ENT don’t have much interest in it, and that’s not who you want to see.
What about psychogenic dizziness and metabolic induced dizziness?
Regarding psychiatric causes of vertigo, I don't see many. The ones I see are usually associated with panic symptoms such as "can't get enough air", shaky hands, paresthesia hands, rapid heart rate, dizziness, dry mouth and feelings of anxiety/panic.
Metabolic induced dizziness such as hypoglycemia/electrolyte disorders, hyper and hypothyroidism usually have other features that might make you suspect it. They certainly wouldn't have the diagnostic features of BPPV/vestibular neuritis/vestibular migraine/posterior circulation stroke.
Thanks from Brazil!
please upload PowerPoint presentation if possible thanks
I don't upload my ppt presentations, sorry.
very good presentation but some slides are blurry