How to implement novel TiTrATE tool to diagnose and classify Vertigo

M3 India Newsdesk Aug 10, 2018

The likely cause of dizziness or vertigo can now be decided with the use of a new diagnostic tool, TiTrATE, considered far superior than conventional diagnostic methods.

The TiTrATE acronym stands for Timings (evolution, onset and duration), potential Triggering factors (situations, actions, movements) and doing A Targeted Examination, based on which the likely cause of the vertigo can be classified as central of peripheral.

The three types of clinical presentation for dizziness are- intermittent triggered, spontaneous episodic, or continuous vestibular.

  • With intermittent triggered symptoms, patients have irregular short intervals of dizziness which lasts for seconds to hours as is seen in benign paroxysmal positional vertigo (BPPV).
  • With spontaneous episodic symptoms (no trigger), sudden episodes of dizziness lasting seconds to days are experienced by patients as seen in Meniere’s disease, vestibular migraine, and psychiatric anxiety disorders.
  • Patients may also have continuous dizziness that may last for days or weeks in the continuous vestibular symptom type. These symptoms are more likely to occur in vestibular neuritis or central etiologies in the absence of injury.

Physical Examination

The physical examination findings along with neurological or cardiovascular findings and other examinations of nose, throat, head, eye and ear are generally performed in patients followed by blood pressure measurement in both sitting and supine positions to check for orthostatic hypotension.

A complete neurological examination should be done in patients with orthostatic dizziness but without hypotension or BPPV. The gait of the patient should be observed for unsteadiness which would suggest peripheral neuropathy. Romberg test should be performed and if positive, is suggestive of a problem in proprioception receptors or pathway functions.

Laboratory Testing & Imaging

Blood and electrolyte evaluation are needed in patients with long term medical problems such as hypertension, and diabetes mellitus. Cardiac diseases should be ruled out with ECG, Holter monitoring, and carotid Doppler testing. If a neurological abnormality is detected, CT and MRI can be done to assess for cerebrovascular disease.

Peripheral etiology

  • Benign Paroxysmal Positional Vertigo: BPPV is caused by dislodgment of loose otoconia (canaliths) into the semicircular canals, most frequently in the posterior canal. BPPV is most commonly seen between 50 and 70 years but can occur at any age. Dix-Hallpike maneuver can detect BPPV, if BPPV persistent timing and trigger are present, and transient upbeat-torsional nystagmus are seen during the maneuver. The Epley maneuver repositions the canalith from the semicircular canal into the vestibule and can treat BPPV in 70% cases on the first attempt, and almost 100% on repeated maneuvers. Medications have no role in its treatment.
  • Vestibular Neuritis: It is presumed to be caused by a virus and is the second most common etiology of vertigo. This disease has an equal gender distribution and affects people between 30 to 50 years of age more frequently. Severe vertigo, nausea, oscillopsia and horizontally rotating spontaneous nystagmus to the unaffected side or an unstable gait with tendency to fall to the affected side can be seen. Development of BPPV after an attack of vestibular neuritis may be seen in 15% of patients although the prognosis is usually excellent, and hearing is not impaired. Vestibular rehabilitation and medications such as anti-emetics and anti-nauseas can be used as treatment but for not more than three days due to issues in blocking central compensation.

Meniere’s Disease

Vertigo and unilateral hearing loss are caused by Meniere disease. It can occur at any age but is often seen between 20 and 60 years. Bed rest is necessary in this condition as it involves severe vertigo, nausea, vomiting, and loss of balance. Initial treatment consists of lifestyle modifications, less caffeine intake, restricting dietary salt intake to less than 2,000 mg daily, and reducing alcohol to one drink per day.

If vertigo does not improve with lifestyle changes, daily thiazide diuretic therapy can be given. To improve vertigo, transtympanic injections of glucocorticoids and gentamicin can also be used. Transtympanic gentamicin should be used only for severe hearing loss. Effective drugs for acute attacks include prochlorperazine, promethazine, and diazepam. Refractory cases can be treated with surgical intervention. Persistent tinnitus or hearing loss may be alleviated by vestibular rehabilitation.

Central Etiologies

Approximately 25% of dizziness is due to central pathologies. Rather than true vertigo, patients may present with disequilibrium and ataxia. An imminent cerebrovascular event may be presented by vertigo. Diagnosis is made by HINTS examination.

HINTS Examination

HINTS- head impulse, nystagmus, test of skew helps to differentiate between peripheral or central etiologies.

  • Head-Impulse: Absence of eye movement most probably suggests a central cause.
  • Nystagmus: Worsening of spontaneous one directional horizontal nystagmus when gazing in the direction of nystagmus implies peripheral causes (vestibular neuritis), whereas spontaneous largely vertical or torsional nystagmus implies central etiology.
  • Test of Skew: Brainstem involvement is usually specifically diagnosed if there is vertical deviation on uncovering the covered eye.

Vestibular Migraine: Among children, vestibular migraine commonly causes episodic vertigo. Adult women are three times more susceptible which is common between the age of 20 to 50 years. Diagnosis can only be made if five moderate or severe vestibular symptoms episodes lasting five to 72 hours occur, patient has history of migraine or presents with migraine and a minimum of 50% vestibular symptoms. Preliminary care involves recognizing and avoiding migraine triggers. Stress relief, adequate sleep and exercise and vestibular suppressant medications have been shown to help.

Vertebrobasilar Ischemia: A history of diplopia, dysarthria, weakness, or clumsiness of the limbs and other brainstem symptoms are required for diagnosis. In 48% of patients, vertigo is seen first, and initial neurologic involvement is seen in less than 50% of patients. Antiplatelet therapy and cerebrovascular disease risk factor reduction are treatment options. In cases of significant vertebral or basilar artery stenosis, warfarin has been used.

Since dizziness is a broad term, and patients have a hard time describing their symptoms clearly, but remember timings and triggers better, TiTrATE holds more clinical significance as an efficient diagnostic method. TiTrATE enables more focused examination of a patient with better health outcomes.

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