Mr. W is a 29-year-old man who arrives at the emergency department with a chief complaint of dizziness. He reports that he was in his usual state of excellent health until about 8 hours ago. At that time, he experienced a fairly intense sensation of dizziness. He describes the sensation as spinning. He also complains of a severe headache with neck pain.
At this point, what is the leading hypothesis, what are the active alternatives, and is there a must not miss diagnosis? Given this differential diagnosis, what tests should be ordered?
RANKING THE DIFFERENTIAL DIAGNOSIS
As noted in Figure 14-1, the first pivotal decision in patients with dizziness is to determine whether the patient is experiencing vertigo, dysequilibrium, near syncope, or ill-defined light-headedness. Mr. W has a sensation of motion and therefore has vertigo. In patients with vertigo, the next pivotal step is to look for neurologic signs or symptoms that suggest whether the pathologic process is coming from the brainstem or cerebellum (Figure 14-2). His headache makes this an obvious consideration. The subset of diseases that cause vertigo and headache include migraine with vertigo (vestibular migraine), cerebellar hemorrhage, intracranial neoplasm, and VAD. Clearly, several of these are potentially life-threatening.
Mr. W reports that he has never experienced vertigo before. He has an occasional headache that resolves with ibuprofen and has never been associated with an aura. He has no known vascular disease and does not have a history of hypertension, diabetes, tobacco use, coagulopathy, atrial fibrillation, or cocaine use. He has no known malignancy. Finally, although he feels that it is unrelated, he mentions that he saw a chiropractor for cervical adjustment about 1 hour before his symptoms started. He reports that he sees his chiropractor regularly and has never had any symptoms subsequently.
On exam he looks fairly uncomfortable. His vital signs are normal except for mild hypertension 140/90 mm Hg. His cranial nerve exam and gait are normal. He has no nystagmus or dysmetria. The remainder of his exam is unremarkable.
Given Mr. W’s young age and overall health, you wonder if he is presenting with a migraine and vertigo. However, all of the alternative hypotheses are potentially life-threatening and are must not miss hypotheses. Table 14-9 lists the differential diagnosis.
Table 14-9.Diagnostic hypotheses for Mr. W. ||Download (.pdf) Table 14-9. Diagnostic hypotheses for Mr. W.
|Diagnostic Hypotheses ||Demographics, Risk Factors, Symptoms and Signs ||Important Tests |
|Leading Hypothesis |
|Vestibular migraine || |
History of recurring throbbing headaches with or without aura
Temporal association of headache and vertigo
Thorough neurologic history and exam to exclude CNS lesions
|Active Alternatives—Must Not Miss |
|Cerebellar hemorrhage || |
Hypertension, cocaine use, anticoagulant therapy
Severe headache at onset, vomiting, ataxia
|Head CT scan or MRI/MRA |
|Vertebral artery dissection || |
Trauma or spinal manipulation
Severe headache or ...