A 65-year-old man comes to the emergency room because of "head spinning" for the last 4 hours. He states that he has severe difficulty with his balance and feels like he is leaning to the right. He denies headache, double vision, muscle weakness, nausea, or vomiting. His past medical history is significant for hypertension, type 2 diabetes mellitus, hyperlipidemia, and mild intermittent asthma. He had a mild upper respiratory infection three weeks ago with a persistent sore throat until last week. His daily medications include glyburide, aspirin, lisinopril, and atorvastatin. He is an ex-smoker with a 35 pack-year smoking history.
His temperature is 36.7 C (98.6 F), blood pressure is 155/92 mm Hg, and pulse is 87/min with regular rhythm. On neurological examination, he is alert and cooperative. Cranial nerve examination reveals an up-beat torsional jerk nystagmus. Mild dysmetria is present on the right upon the finger-to-nose test.
His fingerstick glucose is 75 mg/dL. A non-contrast head CT shows no intracranial bleeding and is otherwise unremarkable.
Which of the following is the next best step in the management of this patient?

Question

A 65-year-old man comes to the emergency room because of "head spinning" for the last 4 hours.  He states that he has severe difficulty with his balance and feels like he is leaning to the right.  He denies headache, double vision, muscle weakness, nausea, or vomiting.  His past medical history is significant for hypertension, type 2 diabetes mellitus, hyperlipidemia, and mild intermittent asthma.  He had a mild upper respiratory infection three weeks ago with a persistent sore throat until last week.  His daily medications include glyburide, aspirin, lisinopril, and atorvastatin.  He is an ex-smoker with a 35 pack-year smoking history.
His temperature is 36.7 C (98.6 F), blood pressure is 155/92 mm Hg, and pulse is 87/min with regular rhythm.  On neurological examination, he is alert and cooperative.  Cranial nerve examination reveals an up-beat torsional jerk nystagmus.  Mild dysmetria is present on the right upon the finger-to-nose test.
His fingerstick glucose is 75 mg/dL.  A non-contrast head CT shows no intracranial bleeding and is otherwise unremarkable.
Which of the following is the next best step in the management of this patient?

Quizplus · Accepted Answer

This patient's clinical presentation is consistent with vertigo, likely due to a central cause. Vertigo is classified as either central or peripheral (summarized in the below table). Peripheral vertigo usually presents with contralateral nystagmus from the affected side that worsens with gaze opposite the lesion and improves with gaze towards the lesion. There is usually a latency period before symptom onset that occurs for only a brief period. 11ec193a_965c_6dc3_853d_d3a4051a0434_MD0002_00 Central vertigo presents with less vertigo and more gait disturbances, disequilibrium, vertical and/or torsional nystagmus, and possible various associated neurological symptoms. There is usually no latency period before the onset of nystagmus. This patient's difficulty with walking favors a more central etiology of the vertigo and should be evaluated with MRI with diffusion protocol for possible acute stroke. (Choice B) A blood glucose of 75 mg/dL is generally not low enough to explain the patient's focal neurological deficits. A serum blood glucose < 50 mg/dL usually causes focal neurological deficits. (Choice C) Vestibular neuronitis (second most common cause of peripheral vertigo) is usually due to herpes virus and presents with sudden vertigo lasting several days. Methylprednisolone hastens recovery, but acyclovir has limited efficacy in improving symptoms. This patient's symptoms are more consistent with central vertigo. (Choice D) Meclizine is appropriate for patients with suspected BPPV, but this patient's nystagmus and dysmetria are more concerning for central vertigo and should be evaluated with urgent brain MRI. (Choice E) Epley's maneuver (vestibular exercises) is a bedside procedure for BPPV and involves moving the patient's head in various directions to reposition the dislodged otolith in the semicircular canals. However, these maneuvers are less effective for central vertigo. Educational objective: Vertigo is classified as peripheral or central. Peripheral vertigo usually presents with more dizziness and is due to benign paroxysmal positional vertigo, Meniere's disease, vestibular neuronitis, or labyrinthitis. Central vertigo presents with more gait disturbances and is due to stroke, multiple sclerosis, migraine, or CNS tumor. MRI of the brain should be done to evaluate patients with central vertigo for acute causes such as stroke. __________ References: Vertigo: A Review of Common Peripheral and Central Vestibular Disorders (http://www.ncbi.nlm.nih.gov/pubmed/21603405) Central vertigo and dizziness: epidemiology, differential diagnosis, and common causes. (http://www.ncbi.nlm.nih.gov/pubmed/19008741)

A 65-Year-Old Man Comes to the Emergency Room Because of "Head