Stroke as a Cause of Vertigo

Strokes in the brain’s cerebellum or medulla can cause Vertigo, but they’re rare.ย  Other causes of Vertigo are much more common.ย  But we have to think about it carefully, and treat rapidly if the following are present.ย  A patient with persistent vertigo, that does not occur in repetitive short bursts lasting seconds (especially occurring with head movement or position change) which would be BPPV should go to an E.R. especially if they have any Stroke Risk Factors below.

“Special Physical Exam Special Maneuvers,” which most clinicians donโ€™t know, are at the end.

Stroke Risk Factors

  • Age >60
  • Hypertension
  • Diabetes
  • Certain autoimmune disorders (Lupus, etc.)
  • Certain heart diseases (atrial fibrillation, metal heart valves, etc.)

The rest of this Post is written in Medical Language.  The purpose is in case you or someone you know goes to an ER because of Vertigo, and have any of the above risk factors for Stroke, you can ask your provider there to reassure you that theyโ€™ve covered everything below.  If not, could they please order all the scans

Stroke Symptoms (vertebro-basilar circulation)

  • diplopia (double vision)
  • dysarthria (slurred speech)
  • dysphagia (trouble swallowing)

Suggestion of Vertebral Artery Dissection (tear)

  • Severe head or neck pain
  • Recent trauma, or exertion involving neck (exercising vigorously, roller-coaster rides, yoga, childbirth, sex, even sneezing or coughing.

Signs of Stroke on Physical Exam (medulla or cerebellum):

  • EOM deficit
  • Rotary or vertical nystagmus
  • Hornerโ€™s Syndrome (unilateral ptosis, miosis, absent sweating)
  • Deficits in Cranial Nerves 9-12 (including hoarseness)
  • Unilateral deficit in coordination (finger-to-nose or heel-down-shin tests)
  • Loss of pinprick sensation involving one side of face & opposite side of trunk
  • Abnormal Romberg with eyes open (in Labyrinthine [Vestibular] Disease, normal position is maintained with feet together & eyes open, but not with eyes closed)
  • If vertigo & nystagmus are actively present during the exam, a normal horizontal Head Thrust (or โ€œhead impulse testโ€)  implies stroke [see below]

Special Maneuversย  —ย  For Patients with both Active Vertigo, and also Active Nystagmus (jerky eyes movements)

One study (citation below) found 100% sensitivity & 96% specificity for Stroke (no false-negatives, very few false-positives) if any of the following 3 tests were positive (when performed on a patient with both active vertigo & nystagmus):

a)  Horizontal Head Thrust (hHT):

  1. Have them focus continuously on a spot straight ahead
  2. Turn their head abruptly to one side
  3. If Labyrinthine disease (not a stroke), response is abnormal: eyes move involuntarily with the head, then dart back to regain focus (bottom pix)
  4. If Stroke, eyes maintain normal focus (just like person without vertigo) (top pix)
http://pn.bmj.com/content/10/3/129/F4.large.jpg

b)  Direction-changing nystagmus with eccentric gaze.

  1. Nystagmus present when staring straight ahead
  2. Ask patient to look to right & then left
  3. If nystagmus starts beating in the the other direction, think Stroke
  4. Watch a video:

c)  Skew (the easiest of the 3 tests)

  1. Patient focuses continuously straight ahead.
  2. Cover one eye.
  3. Uncover it, and cover the other
  4. Keep repeating
  5. If one eye stares off with skewed alignment for a moment when uncovered, think Stroke

Remember  —  All the above imply the patient has both active vertigo and nystagmus, which is not at all common. Hereโ€™s the whole article, written for sophisticated medical professionals:  http://stroke.ahajournals.org/content/40/11/3504.long

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