A 52-year-old woman is brought to the emergency department due to severe dizziness, unsteadiness, and nausea. The spinning sensation began suddenly when the patient's head was tilted back and to the left while getting her hair washed at a salon. When she tried to get out of the chair, she tilted to the left and was unable to sit upright without assistance. She reports no similar symptoms in the past but recently had an upper respiratory illness. Medical history includes hypertension and hyperlipidemia. The patient is an active smoker with a 20-pack-year history and drinks alcohol occasionally. Temperature is 37 C (98.6 F), blood pressure is 144/90 mm Hg, and pulse is 92/min and regular. On physical examination, the patient appears uncomfortable and keeps her eyes closed. The pupils are equal and reactive, and nystagmus is present. Impaired pinprick sensation is present on the left side of the face and right upper and lower extremities. Deep tendon reflexes are normal throughout. Which of the following is the most likely cause of this patient's current condition?

Question

A 52-year-old woman is brought to the emergency department due to severe dizziness, unsteadiness, and nausea.  The spinning sensation began suddenly when the patient's head was tilted back and to the left while getting her hair washed at a salon.  When she tried to get out of the chair, she tilted to the left and was unable to sit upright without assistance.  She reports no similar symptoms in the past but recently had an upper respiratory illness.  Medical history includes hypertension and hyperlipidemia.  The patient is an active smoker with a 20-pack-year history and drinks alcohol occasionally.  Temperature is 37 C (98.6 F), blood pressure is 144/90 mm Hg, and pulse is 92/min and regular.  On physical examination, the patient appears uncomfortable and keeps her eyes closed.  The pupils are equal and reactive, and nystagmus is present.  Impaired pinprick sensation is present on the left side of the face and right upper and lower extremities.  Deep tendon reflexes are normal throughout.  Which of the following is the most likely cause of this patient's current condition?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d53d_d9af_bc81_150d0266b0ca_MD0003_00 This patient with severe vertigo ("spinning sensation"), nausea, and nystagmus accompanied by sensation defects of the left side of the face and right extremities has had a posterior circulation stroke. Given that these stroke symptoms developed after neck extension and torsion (head tilted back and to the left at the hair salon), they were likely due to dissection of the left vertebral artery. Although the most common causes of vertigo (eg, benign paroxysmal positional vertigo [BPPV], vestibular neuritis) are benign, vertigo can be the presenting symptom of a posterior circulation stroke, especially in association with other neurologic signs/symptoms. Posterior circulation strokes can be caused by atherosclerosis, embolism, or vertebral artery dissection, which can occur spontaneously or as a result of minor trauma (eg, sports injuries, neck manipulation). As the artery dissects, ischemia can affect multiple areas of the brain, causing the following: Loss of pain and temperature in the ipsilateral face (spinal trigeminal tract) and contralateral trunk/limbs (spinothalamic tract) Ataxia (inferior cerebellar peduncle) and nystagmus (vestibular nucleus) Dysphagia and dysphonia due to bulbar muscle weakness (nucleus ambiguus) Ipsilateral Horner syndrome (sympathetic tract) Lateral medullary (Wallenberg) syndrome, with the findings illustrated above, is the syndrome most commonly seen with strokes in the intracranial vertebral artery distribution due to occlusion of the posterior inferior cerebellar artery. posterior inferior cerebellar artery (Choice A) Acute vestibular nerve inflammation (ie, vestibular neuritis) can present with sudden-onset vertigo and nystagmus after an upper respiratory infection. However, sensory deficits (eg, impaired pinprick sensation) in the face and the contralateral extremities would not be present. (Choice C) Ménière disease is characterized by distension of the endolymphatic system due to increased volume and/or pressure of endolymph. It presents with episodic vertigo lasting 20 minutes to 24 hours. However, it is accompanied by hearing loss and aural fullness; additional neurologic findings are not present. (Choice D) Occlusion of the middle cerebral artery can cause somatosensory deficits. However, deficits involve the contralateral face and body (rather than the crossed signs seen in this patient) and are usually associated with motor weakness. In addition, aphasia (dominant hemisphere involvement) or hemineglect (nondominant hemisphere involvement) is common. (Choice E) Otolith dislodgment into the semicircular canal describes BPPV, which presents with vertigo and nystagmus triggered by head movement. Episodes are brief (<1 min) and unaccompanied by other neurologic findings. Educational objective: Vertigo accompanied by loss of sensation over the ipsilateral face and contralateral body is concerning for a posterior circulation stroke that can be precipitated by vertebral artery dissection after minor neck trauma. References: Clinical presentation, magnetic resonance angiography, ultrasound findings, and stroke patterns in patients with vertebral artery dissection. (http://www.ncbi.nlm.nih.gov/pubmed/27798932)

A 52-Year-Old Woman Is Brought to the Emergency Department Due