Vertigo en Servicio de Urgencia

1. Vértigo
¿O mandé un ACV a la casa?
Dr. Carlos Basaure V
Emergenciólogo
Departamento Medicina de Urgencia
Universidad de Chile

2. Vértigo
• Sensación de desorientación en el espacio
más sensación de movimiento
• Mareos
• Debilidad
• Nauseas
• Lipotimia

3. Desafío
• ¿Es vértigo?
• ¿Es central o periférico?

4. Equilibrio
•Núcleo vestibular:
• Integra todas las señales en el cerebelo

5. Sistema Vestibular

8. Nistagmo

9. Enfrentamiento
• ¿Es Vértigo?
• Sensación de movimiento
• Nauseas, vómitos, diaforesis, palidez.

10. Enfrentamiento
Vértigo
Periférico Central
SVA Hemorragia
VPPB
Tumor
Meniere Isquemia

11. Enfrentamiento
Vértigo
Periférico Central
SVA Hemorragia
VPPB
Tumor
Meniere Isquemia

12. Enfrentamiento
Vértigo
Periférico Central
SVA Hemorragia
VPPB
Tumor
Meniere Isquemia

13. Enfrentamiento
Vértigo
Periférico Central
SVA Hemorragia
VPPB
Tumor
Meniere Isquemia
Neuritis Vestibular ACV Vertebrobasilar
Esclerosis Múltiple

14. Sindrome Vestibular Agudo
• SVA: vértigo de inicio súbito, nauseas, vómitos,
marcha inestable y imposibilidad de mover la
cabeza y nistagmo que dura días a semanas
• 25% de estos son ACV cerebeloso o de tronco
• TC tiene sens. baja (16%) para fosa posterior
• RNM no esta presente en todas partes
• Menos de a mitad tiene disartria o dismetría

15. Enfrentamiento
• ¿Periférico o central?
• Periférico: episódico, intenso, cambios de
posición, tinítus, hipoacusia
• Central: ataxia, lateropulsión, edad
avanzada, FA, HTA, DM, E Coronaria.
• Asociación a trauma (cuello, craneo)

16. It has clearly been shown that isolated vertigo can be the The abnormal jerk nystagmus of inner ear disease consists
, and only initial symptom of cerebellar and other posterior circula- of slow and quick components. The eyes slowly “drift” in the
asion- tion bleeds, transient ischemic attacks (TIAs), and infarc- direction of the diseased, hypoactive ear, then quickly jerk
ediate Table 12-1 Characteristics of Peripheral and physicians often
tion.11-13 One study showed that emergency back to the intended direction of gaze. Positional nystagmus,
laby- did not make Vertigo diagnosis in patients with validated
Central the correct induced by rapidly changing the position of the head, strongly
quires strokes or TIAs that presented with only vertigo.6 Risk factor suggests an organic vestibular disorder. The characteristics of
denti- CHARACTERISTIC and symptom patterns can beCENTRAL helpful in
assessment PERIPHERAL extremely nystagmus are one of the most valuable tools for distinguishing
deciding which patients warrant imaging and admission. Older peripheral from central causes of vertigo (Table 12-2).
e 12-1
Onset age, male sex, hypertension, coronary artery disease, diabetes
Sudden Gradual or sudden Positional Testing. If nystagmus is not present at rest, positional
l and mellitis, and atrial fibrillation put patients at higher risk. In
Intensity Severe Mild testing can be helpful in determining its existence and char-
addition, frequent episodes lastingor
Duration Usually seconds only minutes weeks,
Usually or prolonged acteristics. In the Hallpike maneuver, the patient is moved
episodes of a day minutes; are more often associated with
or more months quickly from an upright seated position to a supine position,
6,11,12
central processes. occasionally retrospective study showed
A recent (continuous) but and the head is turned to one side and extended (to a head-
emergency physicians often failed to chartcan be seconds
hours, days triggers and dura- down posture) approximately 30° from the horizontal plane off
tion of dizziness, information that could potentially lead to
(intermittent) or minutes with the end of the stretcher. The eyes should be observed for
increased likelihood of a more serious cause of symptoms.14
vascular causes nystagmus and the patient queried for the occurrence of symp-
Past Medical History. Many medications have direct vestibulo-
Direction of One direction Horizontal, rotary,
orma- toxicity. The most commonly encounteredor verticalare the aminogly-
Does nystagmus (usually
cosides, anticonvulsants, alcohols, quinine, quinidine, and
horizontorotary), (different
e or a minocycline. In addition, caffeine and nicotine can have wide-
never vertical directions in Distinguishing Characteristics of Nystagmus
indi- ranging autonomic effects that may exacerbate vestibular Table 12-2 with Central and Peripheral Vertigo
different
r, and symptoms. The history of past and present illnesses should be
positions)
explored, with specific questioning about the existence of dia-
ms of Effect of headdrug or alcohol use,by the risk factors mentioned
Worsened and Little change, CHARACTERISTIC CENTRAL PERIPHERAL
betes,
ertigo position
earlier. position, often associated with Direction Any direction Horizontal or
effect single critical more than one horizontorotary
ave an position position Laterality Unilateral or bilateral Bilateral
Physical Examination
Associated None Usually present
on of Position testing
y, dis- neurologic
Vital Signs. In some cases, pulses and blood pressure should be effects:
findings
checked in both arms. Most patients with subclavian steal Latency Short Long
entral Duration Sustained Transient
Associated auditory
syndrome, whichMay canpresent,
also be cause vertebrobasilar artery insuffi-
None
Intensity Mild Mild to severe
findings
ciency, have pulseincluding or systolic blood pressure differences
often between the two arms. tinnitus
Fatigability Nonfatigable Fatigable
have Effect of visual Not suppressed, may Suppressed
Head and Neck. Carotid or vertebral artery bruits suggest ath- fixation be enhanced
spells. erosclerosis. The neck is auscultated along the course of the
ble to evidence suggesting seizures, syncope, or imbalance unrelated
e able to feelings of vertigo.
iately The time of onset and the duration of vertigo are important
addi- clues to the cause. Episodic vertigo that is severe, lasts several
cover hours, and has symptom-free intervals between episodes sug-

17. Enfrentamiento
• ¿SVA es Central o periférico?
• HINTS
HINTS to Diagnose Stroke in the Acute Vestibular Syndrome : Three-Step Bedside
Oculomotor Examination More Sensitive Than Early MRI Diffusion-Weighted Imaging
Jorge C. Kattah, Arun V. Talkad, David Z. Wang, Yu-Hsiang Hsieh and David E.
Newman-Toker
Stroke. 2009;40:3504-3510; originally published online September 17, 2009;
doi: 10.1161/STROKEAHA.109.551234
Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright © 2009 American Heart Association, Inc. All rights reserved.
Print ISSN: 0039-2499. Online ISSN: 1524-4628
The online version of this article, along with updated information and services, is located on the
World Wide Web at:
http://stroke.ahajournals.org/content/40/11/3504

18. Enfrentamiento
• Head Impulse (HI) :
• Evalúa el reflejo vestíbulo-ocular
• Se fija la mirada en un punto y se gira la
cabeza en 30º de manera aleatoria
• Si esta presente, indica lesión vestibular

19. Head Impulse
(HI)
Prueba POSITIVA
Periférico
Bueno

20. Head Impulse
(HI)
Prueba POSITIVA
Periférico
Bueno

21. Enfrentamiento
• Nistagmo (N)
• Multidireccional, no agotable, alternante

22. Nistagmo “Horizontal”
Horizontal Periférico Bueno

23. Nistagmo “Horizontal”
Horizontal Periférico Bueno

24. Nistagmo “vertical”
Vertical Central Malo

25. Nistagmo “vertical”
Vertical Central Malo

26. Enfrentamiento
• Test of Skew (TS)
• Se cubre un ojo y se pide que fije la
mirada en un punto comandos ojos.
• Central si el ojo examinado esta
desalineado de manera vertical

27. Test of Skew (TS)
Desalineamiento Central

28. Test of Skew (TS)
Desalineamiento Central

29. Enfrentamiento
Sindrome Vestibular Agudo
• Util:
• Múltiples episodios → ACV
• Cefalea o Cervicalgia → LR 3.2
• Sint Neurológicos: ataxia de tronco o lateropulsión
• Head Impulse: Normal LR 18.4 para ACV
• Nistagmo: alternante S30% E98%
• Test Skew: anormal → ACV S38% E98%
• RNM: S83% para ACV

30. Enfrentamiento
Inútil:
• Diferenciar tipo de vértigo
• Onset del vértigo
• Provocación con movimiento
• Proporcionalidad de síntomas (distinto → periférico)
• Hipoacusia
• Parton y vector del nistagmo
• TC Cerebro sin cte. S16% para ACV

31. Enfrentamiento
HINTS
• INFARCT
• Impulso Normal
• Fast-Phase Alternating
• Refixation on Cover Test
• Si 1 de 3 anormal S100% E96% para CENTRAL

32. Vértigos Periféricos
• VPPB:
• Intenso, corta duración, sintomas asociados,
nistagmo reproducible con cambios de
posición
• Meniere:
• Horas de duración, tinítus, hipoacusia,
periodos de ataques frecuentes y periodos
largos asintomáticos, sin nistagmo posicional

33. Sindrome Vestibular Agudo
HINTS
• Head Impulse: anormal
SVA Periférico
• Nistagmo: horizontal, agotable, unidireccional Neuritis Vestibular
• Test Skew: normal

34. FIN