Acute vertigo: Could it be a stroke, Part IV

A Checklist for the Initial Examination of a Patient with Vertigo, Part IV

This checklist is something I came up with at the suggestion of a local family practice physician that said, “Can you give me a checklist of the things I should be looking for, with management recommendations?” A word of caution, this checklist is currently just an idea and has not been validated in any way.

Since the sensitivity and specificity of categorizing a patient as “peripheral” versus “central” is greatly increased when the screening tests are viewed in combination, it is helpful to use a checklist. As you view the checklist will note two columns. The column on the left represents findings considered to be highly specific to peripheral vestibular (labyrinthine) disorders. The column on the right represents physical signs associated with brain stem or cerebellar dysfunction. As the screening exam is carried out, the examiner should mark the appropriate box. If the examiner finds that items on the left are marked, and the right column is unmarked, it is highly likely that the patient suffers from a peripheral labyrinthine disorder. To a large degree, a brain stem or cerebellar pathology has been effectively “ruled out” by identifying that the patients complaints are most likely of peripheral labyrinthine origin. Conversely, if any of the physical signs listed in the right column are noted, brain stem or cerebellar stoke should be investigated by neuro-imaging or neurologic consultation. Physical findings in the left column suggest peripheral labyrinthine etiology. Findings in the right column suggest cerebellar or brain stem etiology.  Note: My apologies for the formatting below.  The columns should be side by side., but I am posting this on Memorial Day and decided not to bother the IT folks.  You get the idea.  A properly formatted checklist can be found in my new book on page 58.

Initial Examination Checklist for Vertigo

Peripheral versus Central

Name _______________________________________________ Date ___________________

Equivocal

No nystagmus

Peripheral

Central

 Direction Fixed Nystagmus

 Nystagmus decrease w/ fixation

 Ambulates unassisted

 Positive Head Thrust exam

 Headshake nystagmus

 Transient Positional Nystagmus

(positive Dix-Hallpike)

Direction Changing Nystagmus 

No decrease w/ fixation 

Ataxia –unable to walk unassisted 

Ocular Misalignment –

Vertical Skew Deviation 

Focal Neurologic Deficit

(hemiplegia, dysarthria, limb ataxia)

New Onset Severe Headache 

 Refer for vestibular exam

Refer for Neuro-Imaging 

Refer for Neurologic Consult 

Next week in the final installment on this series about cerebellar stroke (CS), we will look at some studies showing that following a specific clinical exam protocol allows for identification of patients with CS more efficiently, and far less costly, than ordering a CT or MRI scan.

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About Alan Desmond

Dr. Alan Desmond is the director of the Balance Disorders Program at Wake Forest Baptist Health Center, and holds an adjunct assistant professor faculty position at the Wake Forest School of Medicine. In 2015, he received the Presidents Award from the American Academy of Audiology.