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The Clinical Differentiation of Cerebellar Infarction
from Common Vertigo Syndromes
Erik Viirre MD, PhD , James A. Nelson, MDUniversity of California at San Diego, Department of Surgery, Division of Head and Neck SurgeryAccepted June 1, 2009Western Journal of Emergency Medicine , Volume X, no. 4 : November 2009
Review Article:
Presented By Firyal BalushiORL-HNS, OMSBENT, SQUH24/03/2015
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Introduction
‐ Most patients who present to A/E with isolated vertigo have
benign disorders
‐ 0.7-3% have cerebellar infarction
‐ Commonly overlooked
‐ Because the symptoms overlap substantially with benign conditions
‐ Misdiagnosis rate estimated at 35%
‐ Higher risk for complications
‐ Mortality rate possibly of 40%
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Introduction
‐ Physical examination
‐ Most important diagnostic modality for cerebellar infarction
‐ Present in the majority of patients with cerebellar infarction
‐ Computed tomography is insufficient
‐ Only 26% sensitive for acute stroke
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Objectives‐ To address differentiation of cerebellar infarction from the four
most common vertigo syndromes:
‐ Benign paroxysmal positional vertigo
‐ Meniere’s disease
‐ Migrainous vertigo
‐ Vestibular neuritis
‐ To review the physical diagnosis of cerebellar infarction
‐ To propose indications for neuroimaging
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Vertigo- Definition
‐ Pathologic illusion of movement
‐ Experienced as a spinning/rotating sensation
‐ Due to pathologic imbalance in the peripheral or central vestibular system
‐ Often, patients will merely report feeling dizzy
‐ Further questioning is required to identify vertigo
‐ Differentiating vertigo from imbalance, presyncope and lightheadedness
‐ Studies show that patients use overlapping terms to describe their
experience and even change their minds during a single clinical encounter
‐ Only 17% will not report true vertigo
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Benign Paroxysmal Positional Vertigo
‐ Brief episodes of intense vertigo
‐ Precipitated by a change in position
‐ Head movement – vertically
‐ Lasting less than a minute
‐ Idiopathic
‐ 10% follow a bout of vestibular neuritis
‐ 20% follow an episode of head trauma
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‐ Pathophysiology:‐ An otolith in the posterior semicircular canal
‐ Clinical diagnosis:‐ Dix-hallpike test‐ Torsional nystagmus‐ Holds the seated patient’s head 45° to the left or right‐ Aligns the posterior semicircular canal in the vertical plane
‐ Drops the patient back to the supine position, with the head hanging down off the stretcher 10°-30°‐ This causes a large rotation of the posterior semicircular canal within
its own plane, moving the loose otolith and reproducing the symptoms
‐ The test is considered positive if it provokes the characteristic torsional and vertical nystagmus
Benign Paroxysmal Positional Vertigo
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‐ The sensitivity of the Dix-Hallpike maneuver for BPPV has not
been well-described in the ED setting
‐ Can be differentiated from those with cerebellar infarction by
their episodic and positional symptoms
‐ Those who do not fit this description require consideration of
alternative diagnoses.
Benign Paroxysmal Positional Vertigo
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Meniere’s Disease‐ Chronic inner ear disease with simultaneous vertigo, hearing loss, tinnitus, and aural
fullness
‐ Recurrent Episodes
‐ Last a few hours (Range from 20 minutes to a few days)
‐ Symptoms free in between but possible normal hearing
‐ Requires hearing loss documented on audiologic examination on at least one occasion
‐ Pathophysiology: a buildup of fluid in the endolymphatic compartment leading to
Endolymphatic hydrops
‐ Why?
‐ Pressure difference
‐ Protein deficiency
‐ Fibrosis of the endolymphatic ducts
‐ Diagnosis: Histological
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Meniere’s Disease – Non classical?
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‐ It is not common for a stroke to present with isolated
vertigo and hearing loss
‐ Occurs in only 0.3% of all brainstem infarctions
‐ Present with complete ipsilateral deafness
‐ Unless it is with total ipsilateral deafness
‐ Vertigo with hearing loss indicates a peripheral disorder.
‐ Patients with a negative workup for stroke should be referred
to an otolaryngologist for further testing
Meniere’s Disease
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Migrainous Vertigo‐ Second most common cause of vertigo seen in clinical practice
‐ remains under-recognized!
‐ Half of patients present without headache
‐ Presenting features can vary
‐ Features:
‐ An aura that lasts for a few minutes in 18%
‐ Vertigo lasts for longer than 24 hours in 27%
‐ With normal neurological examination
‐ Diagnosis: Clinical
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‐ Strict criteria require:
‐ Recurrent episodes of vertigo
‐ Formal migraine diagnosis by international headache society criteria
‐ A migraine symptom during the attack
‐ The exclusion of other causes.
‐ Probable Migrainous Vertigo:
‐ used for patients with some elements in the presentation to suggest
migraine but no other identifiable cause.
Migrainous Vertigo
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Vestibular Neuritis‐ Acute vestibular syndrome
‐ Caused by decreased vestibular tone on one side
‐ Etiology: viral infection
‐ Diagnosis: clinical – features :
‐ Gradual onset
‐ Peak during the first day and begin to improve within a few days
‐ The associated vertigo is persistent and ongoing
‐ Positional exacerbation is characteristic, as any head movement
amplifies the disparity in bilateral vestibular tone
‐ Associated autonomic symptoms of nausea and vomiting are prominent
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All previous conditions has vertigo
that varies mainly in duration
but
NONE causes imbalance or limb in-coordination
and finger-to-nose, heel-to-shin, and rapid-
alternating movement testing are all preserved
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Cerebellar Infarction‐ Represents approximately 2.3 % of acute strokes overall
‐ Superior cerebellar artery
‐ Anterior inferior cerebellar artery
‐ Posterior inferior cerebellar artery
‐ Large cerebellar infarcts produce symptoms and signs
localizing to the brainstem
‐ such as diplopia, dysarthria, limb ataxia, dysphagia, and
weakness or numbness
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10% of patients with cerebellar infarction can present with ISOLATED VERTIGO
that is vertigo with no localizing findings on motor, sensory, reflex, cranial nerve, or limb coordination
examination
96% are infarcts of the medial branch of the PICA
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‐ Isolated vertigo due to cerebellar infarction pose a
significant diagnostic challenge
‐ It is known for being frequently misdiagnosed, often
with consequent disability
Cerebellar Infarction
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‐ Features:
‐ History:
‐ Sudden and immediate onset of symptoms
‐ Reaching maximal intensity at once
‐ Examination:
‐ Severe ataxia
‐ Direction-changing nystagmus
Cerebellar Infarction
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‐ Severe Ataxia:
‐ Classical sign of central vertigo
‐ 71% : presents with the inability to walk without
support
‐ 29% : mild to moderate imbalance with ambulation
Cerebellar Infarction
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‐ Direction-changing nystagmus:
‐ Multidirectional nystagmus, or gaze-evoked nystagmus
‐ Nystagmus that changes directions according to the
patient’s gaze
‐ For example, if the patient looks to the right it beats to the
right, and when the patient looks left it beats to the left.
‐ 56% sensitive for cerebellar infarction
Cerebellar Infarction
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84% Present even when no other findings of brainstem
ischemia are present with cerebellar infarction and
isolated vertigo
Ataxia And Direction Changing Nystagmus
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How To Diagnosis?
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Facts‐ Evidence-based recommendations for neuroimaging in the
vertiginous patient have not been established
‐ Based upon currently available evidence, clear indications for
neuroimaging includes
‐ focal neurologic deficit
‐ the inability to walk without support
‐ direction-changing nystagmus
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Neuroimaging‐ When neuroimaging is indicated
‐ MRI with magnetic resonance angiography is considered the
optimal study
‐ With an 83% sensitivity compared to 26% for CT
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His article is a study of 15 cases of missed cerebellar infarction
which showed that all 15 lacked documented performance
of standard neurologic examination and gait
by both teams A/E and ENT
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‐ Evidence cited in this review suggests that even when there are no neurologic deficits, most cases of cerebellar infarction will present with either the inability to walk without support or direction-changing nystagmus.
‐ In a patient with a low prior probability of stroke, the emergency physician will usually have good justification for discharging the patient who has isolated vertigo and a completely normal neurologic and neuro-otologic examination.
‐ Despite that, Prompt evaluation by a neurologist or otolaryngologist is recommended for patients who have not received a definite diagnosis
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‐ Thank you.