|Year : 2021 | Volume
| Issue : 2 | Page : 206-208
Acute brain stem vertigo without neurological deficits
Santosh Kumar Swain
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India
|Date of Submission||09-Dec-2020|
|Date of Decision||04-Jan-2021|
|Date of Acceptance||08-Feb-2021|
|Date of Web Publication||24-Aug-2021|
Prof. Santosh Kumar Swain
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University, Kalinga Nagar, Bhubaneswar - 751 003, Odisha
Source of Support: None, Conflict of Interest: None
An infarct at the brain stem or cerebellum is rarely associated with vertigo without any other localizing clinical features. Stroke at the posterior circulation of the brain may cause spontaneous vertigo and imbalance. In some cases, isolated posterior inferior cerebellar artery infraction presents isolated vertigo and nystagmus. The diagnosis of the brain stem vertigo can be done easily when associated with other neurological symptoms along with vertigo, whereas, when the vertigo occurs in isolation, it may be difficult to differentiate it from the other benign disorders affecting the inner ear. A head impulse test may differentiate the acute isolated vertigo with cerebellar stroke from more benign disorders associated with labyrinth. Appropriate evaluation of the patient is better than imaging for diagnosis of the brain stem vertigo. Here, we are presenting a case of isolated acute onset of the vertigo due to brain stem infarct which mimics to the peripheral vestibular pathology.
Keywords: Brain stem, head impulse test, isolated vertigo, vertebrobasilar insufficiency
|How to cite this article:|
Swain SK. Acute brain stem vertigo without neurological deficits. BLDE Univ J Health Sci 2021;6:206-8
Vertigo is a common clinical presentation at the routine clinical practice. Vertigo or dizziness is a nonspecific symptom where the patient describes a sensation of altered orientation in the space. Labyrinthine, visual, and proprioceptive signals are three important sources of information for marinating the position of the head and body in the space and injury to any of these systems may cause dizziness or vertigo. Furthermore, the alteration or injury in the brain stem which integrate these orientation signals can lead to vertigo. The episodic vertigo may be seen in patient suffering from ischemia at the territory of the vertebrobasilar circulation. Stroke is a leading and challenging concern for clinicians. It may be associated with isolated vertigo or along with other symptoms of the vertebrobasilar insufficiency or symptoms and signs of the infraction of the cerebellum and brainstem. Approximately 20% ischemic event in the brain affects the neural structures supplied by the vertebrobasilar circulation and dizziness is the most common symptom in vertebrobasilar diseases. Typically, the vertigo in this clinical condition is abrupt in onset and stays for minutes. As the labyrinth is supplied by the vertebrobasilar circulation, the inner ear symptoms are usual with ischemia in this distribution. The inner ear may be selectively affected as it is an end artery with very minimal collaterals. Here, we are presenting a case report of brain stem vertigo with acute onset in an elderly person.
| Case Report|| |
A 68-year-old male attended the emergency department with complaints of severe vertigo for duration of 3 h. He was known case of hypertension under treatment. The vertigo was sudden in onset and continuous in nature. He has no hearing loss, ear discharge, tinnitus, ear pain, and aural fullness. He has also complained of mild headache which was holocranial in nature. He had no other neurological presentations. Otoscopic examination showed normal tympanic membrane in both sides with normal hearing in tuning fork test. He had spontaneous horizontal Grade-I nystagmus with fast component toward the right side; however, the direction of the nystagmus was changing in eccentric gaze. The head impulse test was negative. He had no cerebellar signs. The patient was hospitalized for observation. Magnetic resonance imaging (MRI) of the brain was done which showed an acute ischemic infarct at the left side cerebellum near posteroinferior cerebellar arteries (PICA) territory [Figure 1]. After hospitalization, he developed slurring of the speech, dysdiadokokinesia, and past pointing. Then, the patient was transferred to the intensive care unit for the treatment of the stroke. The stroke was treated by the neurophyscian. During the treatment time, he also showed atrial fibrillation which was managed by the cardiologist. Initially, it was thought that vertigo and associated symptoms were pointing toward peripheral vestibulopathy; however, change in direction of the nystagmus, negative head impulse test along with slurring of the speech, and other cerebellar sings indicates central vertigo.
|Figure 1: T2-weighted magnetic resonance imaging showing infarction (yellow arrow mark) at the left lobe of the cerebellum|
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| Discussion|| |
The vertigo or dizziness is a common symptom seen in daily clinical practice. The common etiology of the vertigo is peripheral vestibular disease; however, the central nervous system diseases such as cerebrovascular disorders, tumor at the posterior cranial fossa, multiple sclerosis, and neurodegenerative disorders can also manifest vertigo. Monosymptomatic acute vertigo along with nystagmus and no other brain stem symptoms and signs would be rare in case of brain stem ischemia as in this case. The selective ischemic injury to the vestibular nuclei and root entry zone of the vestibular nerve at the pontomedullary junction can also cause isolated vertigo. The patient with infarction at the anterior inferior cerebellar artery (AICA) territory may present with clinical symptoms of recurrent vertigo, tinnitus, fluctuating hearing loss as in Meniere's disease for 1–10 days before to permanent infarction. The vertebrobasilar arterial system supplies the medulla, pons, midbrain, cerebellum, occipital lobes, posterior temporal lobes, and thalamus. This arterial system has extra-cranial and intracranial vertebral arteries of both sides, which unite to form the basilar artery, and it runs midline on the ventral surface of the brain stem, supplying by its small and deep perforators. After that, it merges with the circles of Wills to give off the superior cerebellar arteries and posterior cerebral arteries. The intracranial vertebral arteries give PICA and basilar artery which give rise to AICA. The location of the lesion in case of patients with vascular vertigo can be varied. Few common causes for posterior circulation stroke include embolism of the intracranial vertebral arteries AICA and PICA which leads to cerebellar ischemia, the embolism at the distal part of the basilar artery which can lead to infarcts at the upper cerebellum, midbrain, thalamus, and territories of the posterior cerebral artery, so called as top-of-the-basilar infarcts. Ischemia at the territory of the intracranial vertebral arteries cause lateral medullary syndrome and affecting the basilar artery, leading to the bilateral and crossed symptoms and signs. Vertebrobasilar ischemia or posterior circulation stroke comprises approximately 20% of all the strokes.
Study showing that there is a 2-fold higher chance of stroke in patient with acute vertigo attending the emergency department than those without vertigo and also there is a 3-fold higher chance of posterior circulation stroke among patients hospitalized with isolated vertigo in general population during follow-up time of 3-year period. Hence, vertigo patient may be a case of the evolving stroke and even isolated vertigo at initial presentation. A clinical tool is made for predicting the stroke among vertigo patients. This tool utilizes ABCD score which includes age, blood pressure, clinical features, duration of transient ischemic attack, and presence of diabetes for assessing the risk of stroke in these patients. One study showed around 1% of the vertigo patients with a score of 3 or less had a cerebrovascular stroke as compared to 8.1% of the patients with a score of 4 or more. ABCD score is very useful for assessing the chance of stroke and the imaging of the brain should advise accordingly. A serial imaging may be required for small infarct as it may be missed in early imaging. Study showing false-negative MRI may occur with acute vertebrobasilar strokes. Hence, bedside clinical findings are often needed to identify the patients with central pathology. The patient often present with isolated vertigo typically occurs abruptly and lasts for minutes.
The bed side clinical test for predicting the stroke in a setting of acute vertigo is horizontal head impulse test (h-HIT) which can reveal a defect in vestibule-ocular reflex function. This h-HIT was first documented in 1988 by Halmagyi and Curthoys as bedside test for the evaluation of the peripheral vestibulopathy. This test can also be used to differentiate between peripheral vertigo from stroke. Vertical or torsional nystagmus point toward the central pathology, whereas stroke patient present with acute vertigo with nystagmus of commonly horizontal vector and often mimics to the peripheral vestibular diseases. A change in direction on eccentric gaze differentiates the central vertigo from peripheral vertigo. Skew deviation is another clinical predictor for central pathology in acute vertigo. The skew deviation is vertical ocular misalignment because of imbalance of vestibular neural firing from two sides of the oculomotor system. Skew deviation is often helpful for the predicting central pathology. There is belief that isolated vertigo is usually due to peripheral vestibular pathology. However, in current scenario, early imaging has shown isolated vertigo without any other localizing neurological signs, many a times to be originating from the brain stem and cerebellar strokes. It has been documented in the medical literature that one episode of isolated vertigo was found in 62% of the vertebrobasilar ischemia patients, and in 19% of them, it was initial symptom which often further progressed. Hence, these patients should be shifted to stroke unit under neurophyscian for proper treatment.
| Conclusion|| |
Patients with isolated vertigo are at high risk for manifesting stroke than the healthy general population. Hence, the vertigo patients should undergo a comprehensive neurological examination. The labyrinthine infarction should be thought in older patients with a history of acute onset of unilateral hearing loss, vertigo with a history of the stroke, or known vascular risk factors. Negative head impulse test, positive skew deviation, and direction changing nystagmus on eccentric gaze are common signs and indicates toward sinister central pathology than benign peripheral vestibular pathology. In some patients, initial MRI of the brain may be negative in evolving stroke, but these signs help to hospitalize the patient for observation and repeat imaging in later date for confirmation of the brain stem stroke. In case, an elderly patient presenting with acute isolated vertigo, a differential diagnosis of central vertigo should be entertained if there are no signs of neurological deficits.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Swain SK, Anand N, Mishra S. Vertigo among elderly people: Current opinion. J Med Soc 2019;33:1. [Full text]
Savitz SI, Caplan LR. Vertebrobasilar disease. N Engl J Med 2005;352:2618-26.
Kerber KA, Brown DL, Lisabeth LD, Smith MA, Morgenstern LB. Stroke among patients with dizziness, vertigo, and imbalance in the emergency department: A population-based study. Stroke 2006;37:2484-7.
Kim HJ, Lee SH, Park JH, Choi JY, Kim JS. Isolated vestibular nuclear infarction: Report of two cases and review of the literature. J Neurol 2014;261:121-9.
Lee H, Cho YW. Auditory disturbances as a prodrome of anterior inferior cerebellar infaraction. J Neurol Neurosurg Psychiatry 2003;74:1644-8.
Caplan LR, Wityk RJ, Glass TA, Tapia J, Pazdera L, Chang HM, et al
. New England medical center posterior circulation registry. Ann Neurol 2004;56:389-98.
Lee CC, Su YC, Ho HC, Hung SK, Lee MS, Chou P, et al
. Risk of stroke in patients hospitalized for isolated vertigo: A four-year follow-up study. Stroke 2011;42:48-52.
Johnston SC, Rothwell PM, Nguyen-Huynh MN, Giles MF, Elkins JS, Bernstein AL, et al
. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet 2007;369:283-92.
Newman-Toker DE, Kattah JC, Alvernia JE, Wang DZ. Normal head impulse test differentiates acute cerebellar strokes from vestibular neuritis. Neurology 2008;70:2378-85.
Halmagyi GM, Curthoys IS. A clinical sign of canal paresis. Arch Neurol 1988;45:737-9.
Halmagyi GM. Diagnosis and management of vertigo. Clin Med (Lond) 2005;5:159-65.
Brodsky MC, Donahue SP, Vaphiades M, Brandt T. Skew deviation revisited. Surv Ophthalmol 2006;51:105-28.
Chang TP, Wu YC. A tiny infarct on the dorsolateral pons mimicking vestibular neuritis. Laryngoscope 2010;120:2336-8.
Grad A, Baloh RW. Vertigo of vascular origin. Clinical and electronystagmographic features in 84 cases. Arch Neurol 1989;46:281-4.