Acute Vertigo – Could it be a Stroke, Part III

Alan Desmond
May 21, 2011

Is there a better way to manage patients with suspected stroke causing dizziness ? Part III

Because of the low incidence of dizziness caused by Cerebellar Stroke (CS), as well as the increased cost and reduced availability of MRI scanners, screening protocols to determine which patients require MRI scanning should be developed and followed in both Emergency Departments and primary care settings.
David Solomon, a noted neurologist at Johns Hopkins University, offers the following suggestions: Note: The items in quotes are from Dr. Solomon, the additional comments are mine (ALD).
A patient presenting with acute vertigo should be referred for emergent neuro-imaging (MRI) when accompanied by:
1. “Unilateral or asymmetrical hearing loss” – Unilateral hearing loss may be the result of labyrinthine disorders such as Meniere’s disease or labyrinthitis, but may also be the result of vestibular schwannoma or infarction of the anterior inferior cerebellar artery (AICA).
2. “Brainstem or cerebellar symptoms other than vertigo”
3. “Stroke risk factors” (diabetes, hypertension, history of Myocardial Infarction).
4. “Acute onset associated with neck pain” – Neck pain associated with vertigo is considered a sign of possible vertebral artery dissection .
5. “Direction changing spontaneous nystagmus” – Additionally, nystagmus that are vertical or do not diminish with visual fixation suggest central involvement.
6. “New onset severe headache” – Migraine is known to cause episodic vertigo accompanied by headache, however, Migraine patients typically have a history of prior headache .
7. “Inability to stand or walk” – This is often the most obvious clinical sign differentiating the patient with acute labyrinthine vertigo from a patient with cerebellar or brainstem stroke. Even the most severely vertiginous labyrinthine patient can typically walk a few steps. If the patient cannot stand or walk unassisted, stroke should be suspected .
Next week – What is the best method to evaluate a patient with dizziness suspected to be the result of cerebellar stroke (CS)?

Solomon, D. (2000). Distinguishing and treating causes of central vertigo. Otolaryn Clin of North Amer, 33(3), 579-601

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