An elderly woman with MDS, PV, vascular disease presents with worsening vertigo lasting minutes to an hour. Given her comorbidities and initial inability to walk, we were concerned for central causes of vertigo; however, MRI (without contrast due to RF) was unchanged and the patient ultimately improved with PT and meclizine.
We discussed distinguishing peripheral vs central vertigo. While there is no perfect way to distinguish these two, typically the two differ in their timing, severity, and presence of auditory symptoms.
Peripheral vertigo: Sudden, intermittent, and severe, often with hearing loss. According to the JAMA rational clinical exam (http://jama.jamanetwork.com/article.aspx?articleid=36387), a consistently positive Dix-Hallpike maneuver is also quite specific for peripheral vertigo.
Central vertigo: Gradual, constant, not associated with auditory symptoms.
Thank you Ben for this awesome vertigo handout:
A note on gadolinium and risk of nephrogenic systemic fibrosis (NSF):
-For patients with a STABLE creatinine and GFR < 30, one should weigh risks and benefits before administering gad (our patient’s GFR was ~19, so definitely good to hold off if able!)
-Although there is no clear evidence that HD after gadolinium decreases risk of NSF, experts still recommend it if a patient is on HD and has eGFR < 15
Maneuvers for BPPV (see video in link):