A 72-year-old woman comes to the emergency department due to acute dizziness for 6 hours. The patient awoke this morning with the persistent sensation of "the room spinning around," which becomes worse with head movement. She also has nausea and vomiting, but no headache or vision problems. Nothing seems to relieve her symptoms.
Her other medical problems are hypertension and hyperlipidemia. Home medications include amlodipine and atorvastatin.
Temperature is 36.7 C (98 F), blood pressure is 160/90 mm Hg, and pulse is 84/min. On examination, the patient has bidirectional nystagmus. Muscle strength, light touch and pain sensation, and reflexes are normal throughout. The patient's gait is unsteady and she tends to fall toward the right side.
Blood sugar is 140 mg/dL and electrolytes are normal. Noncontrast CT scan of the head is normal. ECG reveals normal sinus rhythm.
Which of the following is the best next step in management of this patient?

Question

A 72-year-old woman comes to the emergency department due to acute dizziness for 6 hours.  The patient awoke this morning with the persistent sensation of "the room spinning around," which becomes worse with head movement.  She also has nausea and vomiting, but no headache or vision problems.  Nothing seems to relieve her symptoms.
Her other medical problems are hypertension and hyperlipidemia.  Home medications include amlodipine and atorvastatin.
Temperature is 36.7 C (98 F), blood pressure is 160/90 mm Hg, and pulse is 84/min.  On examination, the patient has bidirectional nystagmus.  Muscle strength, light touch and pain sensation, and reflexes are normal throughout.  The patient's gait is unsteady and she tends to fall toward the right side.
Blood sugar is 140 mg/dL and electrolytes are normal.  Noncontrast CT scan of the head is normal.  ECG reveals normal sinus rhythm.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_967a_7d28_853d_15701b8c7b1f_MD0002_00 This patient's presentation of acute, sustained vertigo with bidirectional nystagmus is concerning for cerebellar stroke. Cerebellar stroke can be difficult to distinguish from other causes of vertigo, particularly vestibular neuritis. Up to 25% of patients age >50 who come to the emergency department with acute-onset isolated vertigo have cerebellar infarction rather than vestibular neuritis. Characteristics of nystagmus can help distinguish central from peripheral causes of vertigo: vertigo Peripheral disease (eg, vestibular neuritis, Ménière disease) causes a suppressible nystagmus that does not reverse direction; it beats away from the lesion.Central disease (eg, cerebellar stroke, multiple sclerosis) causes a nonsuppressible nystagmus that can reverse direction (eg, bidirectional); it often beats toward the lesion. Peripheral disease (eg, vestibular neuritis, Ménière disease) causes a suppressible nystagmus that does not reverse direction; it beats away from the lesion. Central disease (eg, cerebellar stroke, multiple sclerosis) causes a nonsuppressible nystagmus that can reverse direction (eg, bidirectional); it often beats toward the lesion. Features suggestive of cerebellar stroke include limb ataxia, inability to ambulate, falling/nystagmus to the side of the lesion, and symptoms persisting for >72 hours. In addition to neurologic abnormalities (eg, dysmetria, dysdiadochokinesia), the presence of persistent hiccups is supportive. Cerebellar stroke is more common in elderly patients with cardiovascular risk factors. Neuroimaging should be obtained in patients with vertigo if there are risk factors for stroke, new headache or neurologic deficits, or features consistent with a central lesion. MRI and MR angiography are the preferred studies given their high sensitivity/specificity in detecting acute cerebellar infarction and posterior circulation occlusion, respectively. CT scan is less sensitive in detecting posterior fossa abnormalities and may be normal within the initial hours of stroke onset. (Choice A) Audiometry has limited utility in the evaluation of vertigo but may be used to assess hearing loss in patients with suspected Ménière disease or vestibular schwannoma. (Choice B) Carotid ultrasound is of limited use in this patient with cerebellar/posterior circulation signs (eg, vertigo, nystagmus, ataxia). (Choice C) The Epley maneuver is a particle-repositioning maneuver that can be used to treat benign paroxysmal positional vertigo (BPPV). Although BPPV may present with nystagmus and vertigo provoked by head movement, nystagmus is typically unidirectional rather than bidirectional, symptoms are typically brief (usually seconds), and ataxia is usually absent. Epley maneuver (Choice E) Reassurance and short-term use of antihistamines such as meclizine may be considered for symptomatic treatment of peripheral vertigo (eg, vestibular neuritis). However, this patient has risk factors and clinical findings consistent with cerebellar stroke that must be excluded first. Educational objective: Features of cerebellar stroke include persistent vertigo, limb ataxia, falling/nystagmus to the side of the lesion, inability to ambulate, and symptoms persisting >72 hours. It is common in patients with advanced age and other cardiovascular risk factors. MRI and MR angiography are the preferred diagnostic studies. __________ References: Initial evaluation of vertigo. (http://www.ncbi.nlm.nih.gov/pubmed/16445269)

A 72-Year-Old Woman Comes to the Emergency Department Due to Acute