A 62-year-old woman who works as a high school administrative assistant is brought to the emergency department by her coworker. She states that 2 hours ago she suddenly felt dizzy while sitting at her desk. A short time later, the patient tried to stand to go to the bathroom and felt like she was falling to the left. Her symptoms have been constant and disabling since they started. The dizziness is exacerbated by any movement of the head, and she has a mild posterior headache. Medical history is significant for hypertension. Temperature is 37.2 C (99 F), blood pressure is 160/85 mm Hg, pulse is 78/min, and respirations are 16/min. The patient is awake and alert. Heart and lungs sounds are normal. Strength is 5/5 in the upper and lower extremities bilaterally. Finger-to-nose and heel-to-shin testing are abnormal on the left. Gait is ataxic. Noncontrast CT scan of the head is normal. ECG shows normal sinus rhythm. Which of the following is the best next step in management of this patient?

Question

A 62-year-old woman who works as a high school administrative assistant is brought to the emergency department by her coworker.  She states that 2 hours ago she suddenly felt dizzy while sitting at her desk.  A short time later, the patient tried to stand to go to the bathroom and felt like she was falling to the left.  Her symptoms have been constant and disabling since they started.  The dizziness is exacerbated by any movement of the head, and she has a mild posterior headache.  Medical history is significant for hypertension.  Temperature is 37.2 C (99 F), blood pressure is 160/85 mm Hg, pulse is 78/min, and respirations are 16/min.  The patient is awake and alert.  Heart and lungs sounds are normal.  Strength is 5/5 in the upper and lower extremities bilaterally.  Finger-to-nose and heel-to-shin testing are abnormal on the left.  Gait is ataxic.  Noncontrast CT scan of the head is normal.  ECG shows normal sinus rhythm.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d53e_9d00_bc81_773a6c804285_MD0003_00 This patient has sudden-onset, persistent vertigo (eg, dizziness, sensation of falling to the left) associated with a posterior headache and unilateral dysmetria (ie, impaired coordination causing an error in accuracy of voluntary movements). This constellation of symptoms is most concerning for left-sided cerebellar stroke. Vertigo can be due to an underlying disease in either the central or peripheral nervous system. Features suggestive of ischemia in the posterior circulation as the cause of central vertigo include the following: posterior circulation central vertigo Limb ataxia or dysmetria (eg, abnormal finger-to-nose or heel-to-shin testing) Postural instability that may manifest with the patient falling to one side (typically toward the side of the lesion) Headache (due to trigeminal innervation of much of the cerebral arterial vasculature) This patient has no evidence of hemorrhage on noncontrast CT scan of the head; therefore, she should receive treatment for ischemic stroke. Because she is being seen within 4.5 hours of symptom onset, thrombolysis with intravenous alteplase is the best next step in management. Patients with suspected cerebellar stroke are treated with thrombolysis even in the absence of classic stroke symptoms (eg, weakness, aphasia). ischemic stroke (Choice B) Oral meclizine and physical therapy are used to treat vestibular neuritis, which can cause peripheral vertigo. However, this patient's dysmetria (eg, abnormal finger-to-nose and heel-to shin-testing) and headache are more consistent with central vertigo due to a cerebellar stroke. (Choice C) Carotid ultrasound may be obtained nonemergently to detect opportunities for stroke prevention (eg, carotid endarterectomy) following initial ischemic stroke management (eg, alteplase). Although it may be eventually indicated in this patient, reperfusion therapy to restore cerebral blood flow takes precedence. (Choice D) Tilt table testing may be used to diagnose vasovagal or orthostatic syncope, which can cause lightheadedness interpreted by some patients as dizziness. However, the lightheadedness (due to cerebral hypoperfusion) does not cause ataxia or dysmetria and typically lasts only seconds to minutes (vs 2 hr). (Choice E) Canalith repositioning maneuvers are used to treat benign paroxysmal positional vertigo (BPPV). BPPV causes peripheral vertigo worsened by head movement; however, episodes are typically brief (<1 min) and lacking other neurologic symptoms (eg, dysmetria, headache). Educational objective: Sudden-onset, persistent vertigo accompanied by other neurologic symptoms (eg, dysmetria, ataxia, headache) is concerning for posterior circulation ischemia (eg, cerebellar stroke). Thrombolysis with intravenous alteplase should be administered to eligible patients with suspected ischemic stroke, even if classic stroke symptoms (eg, weakness, aphasia) are absent. References: Ischemic posterior circulation stroke: a review of anatomy, clinical presentations, diagnosis, and current management. (http://www.ncbi.nlm.nih.gov/pubmed/24778625)

A 62-Year-Old Woman Who Works as a High School Administrative