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Severe Dizziness or Vertigo, Is It a Stroke or Something Else?

Severe dizziness or vertigo

When my elderly mother experienced a bout of severe dizziness, her doctor immediately performed a bedside examination and procedure that gave her nearly instant relief. She was fortunate to be the recipient of what a new study says should be done in the vast majority of cases of vertigo rather than expensive and unnecessary head CT scans that look for stroke.

Dizziness is being overmanaged

Experts at Johns Hopkins say that huge sums of money could be saved if doctors in the emergency room (ER) stopped automatically ordering head CT (computed tomography) scans when people showed up complaining of severe dizziness. Although severe dizziness, or vertigo, can be a symptom of a stroke, only about 5 percent of patients who report this as their main complaint actually experience a stroke, while the rest typically have a common benign inner ear problem.

Vertigo, usually occurs when there is a sudden or temporary change in how the vestibular system (inner ear structures) perform or in how this system communicates or interacts with the brain. Vertigo can be so severe that merely turning your head slightly can cause nausea, vomiting, and a loss of balance.

The most common cause of vertigo is benign paroxysmal positional vertigo (BPPV), which is the condition my mother experienced. People with BPPV are overwhelmed by brief but intense episodes of severe dizziness when they, for example, sit up in bed in the morning or turn over.

Fortunately, BPPV can be effectively diagnosed and treated with simple bedside procedures (see below).

What the new study on severe dizziness shows
An analysis of data conducted by the Johns Hopkins researchers revealed the following:

  • The number of annual emergency room visits for dizziness rose by 97 percent from 1995 to 2011: that is, from 2 million to 3.9 million
  • The proportion of those visits for dizziness that involved the use of advanced imaging increased from 10 percent in 1995 to nearly 40 percent in 2011
  • Use of advanced scans also increased during the same period among patients who did not complain of dizziness, from 3.4 percent to 19 percent

There are several issues concerning CT scans, according to the study’s leader, David E. Newman-Toker, MD, PhD, an associate professor of neurology at the Johns Hopkins University School of Medicine. One is that while such scans can detect hemorrhagic stroke (which makes up only about 15% of all strokes), this condition is rarely the cause of dizziness.

Newman-Toker explains that “we need to realign our resources so that we image only the patients who need it, not the ones who don’t….Accurately and efficiently separating inner-ear patients from the other dizzy patients who probably have strokes will save lives and money.”

Less than 5 percent of patients who visit the emergency department with dizziness should get a CT, according to Newman-Toker. He also suggested that magnetic resonance imaging (MRI) scans could be used in about 6 percent of dizzy patients in the ER.

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Even though MRIs cost up to four times as much as a CT, Newman-Toker pointed out that their use would still offset the costs of CT and unnecessary hospital admissions for patients who really have a benign inner ear disorder while also improving diagnoses. The savings, he noted, could be an estimated $1 billion per year.

So how should people with extreme dizziness be tested? Newman-Toker offered several options, and they all involve the eyes.

For example, doctors could perform three simple eye movement tests at bedside to identify vertigo associated with an inner-ear problem. These tests are “nearly perfect, and even better than MRI in the first two days after symptoms begin,” noted Newman-Toker, but they require physicians who are experts at knowing what to look for.

Another option is the use of a video-oculography machine that can detect extremely small movements of the eyes. While an instrument measures the speed of the head movements, software interprets how the eyes respond, which can allow doctors to distinguish strokes from benign inner-ear problems with 100 percent accuracy.

Other causes of vertigo
Severe dizziness can be caused by several other benign inner-ear problems as well.

  • Inner ear inflammation (also known as acute vestibular neuritis), which can last for days and be accompanied by nausea, vomiting, balance problems, and sudden hearing loss. This condition usually goes away on its own, but medical treatment can help resolve it sooner
  • Vestibular migraine, in which individuals can experience vertigo either with or without the severe head pain associated with migraine. Individuals may also be hypersensitive to light and sound
  • Meniere’s disease, which is characterized by an accumulation of fluid in the inner ear and sudden episodes of vertigo that can last up to several hours. Individuals also experience ringing in the ear, varying hearing loss, and a feeling of fullness in the ear
  • Acoustic neuroma, which is a benign growth that develops on the nerve connecting the inner ear to the brain. People with an acoustic neuroma typically experience progressing loss of hearing, imbalance, and ringing of the ear
  • Rarely, vertigo is a symptom of stroke, multiple sclerosis, or a brain hemorrhage, and in these cases individuals usually also experience double vision, slurred speech, severe balance problems, and weakness or numbness of the face.

Treating severe dizziness
Treatment of severe dizziness depends on the cause. Medications such as antihistamines, scopolamine, or sedatives can help suppress the vestibular system, while antiemetics can be taken to manage nausea and vomiting.

People who experience Meniere’s disease may take a diuretic to help reduce inflammation and fluid buildup, and dietary changes (e.g., reducing salt intake) may also help. Surgical procedures for Meniere’s disease and for acoustic neuroma are also options.

For BPPV, treatment usually includes head exercises or movements that a doctor can perform in the office. These exercises cause particles that have accumulated in the inner ear to move out of the canals, where they can cause vertigo.

Severe dizziness or vertigo can be a frightening and life-altering condition, but in most cases it is not a sign of stroke. Emergency room physicians need to be better trained and equipped to make the distinction between stroke and the much more common benign inner ear conditions associated with severe dizziness or vertigo.

Johns Hopkins University School of Medicine

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