A 64-year-old woman is brought to the emergency department due to sudden-onset headache associated with nausea, vomiting, and a sensation that the "room is spinning." The patient first noticed the symptoms yesterday when she awoke, and they have not improved. She has had no ear pain, hearing loss, fever, or chills. She was recently prescribed hydrochlorothiazide and lisinopril for hypertension. Medical history also includes type 2 diabetes mellitus and hyperlipidemia. The patient does not use tobacco or alcohol. Blood pressure is 124/76 mm Hg and pulse is 86/min. Neurologic examination with the patient lying still shows pure rotatory nystagmus but no extremity weakness or sensory loss. Walking causes worsening of symptoms, and the patient falls toward the left side. Finger-stick glucose is 145 mg/dL. Complete blood count and serum electrolytes are within normal limits. Which of the following is the best next step in management of this patient?

Question

A 64-year-old woman is brought to the emergency department due to sudden-onset headache associated with nausea, vomiting, and a sensation that the "room is spinning."  The patient first noticed the symptoms yesterday when she awoke, and they have not improved.  She has had no ear pain, hearing loss, fever, or chills.  She was recently prescribed hydrochlorothiazide and lisinopril for hypertension.  Medical history also includes type 2 diabetes mellitus and hyperlipidemia.  The patient does not use tobacco or alcohol.  Blood pressure is 124/76 mm Hg and pulse is 86/min.  Neurologic examination with the patient lying still shows pure rotatory nystagmus but no extremity weakness or sensory loss.  Walking causes worsening of symptoms, and the patient falls toward the left side.  Finger-stick glucose is 145 mg/dL.  Complete blood count and serum electrolytes are within normal limits.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d543_30e7_bc81_19ac81d1d988_MD0003_00 This patient with vascular risk factors, acute-onset headache, a sensation that the room is spinning, and nystagmus likely has had a stroke or hemorrhage affecting the cerebellum. Vertigo is often described as a sensation of spinning (as in this patient), whirling, or tilting and can be due to an underlying disease in either the central or peripheral nervous system. Patients with central vertigo have nystagmus that is not fatigable and not inhibited by fixation of gaze. They may be unable to walk because, in addition to a false sensation of movement, vertigo from a central underlying cause (eg, stroke) may also affect postural stability and coordination. Patients with central vertigo, such as this woman, should be evaluated for cerebellar stroke or hemorrhage, particularly if they have: prominent stroke risk factors (eg, hyperlipidemia, hypertension, diabetes mellitus). new-onset headache. neurologic signs/symptoms (eg, weakness/numbness of the face or limbs, dysarthria). Head imaging should be obtained urgently. A CT scan is often obtained first because it can be completed faster than MRI. However, if the CT scan is negative, MRI of the brain is usually required to exclude brainstem or cerebellum pathology, which may not be visualized well on CT scan. (Choice A) Ambulatory ECG monitoring can diagnose underlying cardiac arrhythmias or conduction abnormalities. However, the "dizziness" at presentation is typically presyncope or syncope rather than vertigo. (Choice B) Hydrochlorothiazide is a diuretic that can cause hypotension and hyponatremia (not seen in this patient), which may result in lightheadedness or presyncope. However, it does not cause a true spinning vertigo. (Choice D) Meclizine, an antihistamine, may be used as a vestibular suppressant for episodes of vertigo from a variety of conditions (eg, labyrinthitis, motion sickness). Patients with acute central vertigo require evaluation for stroke or hemorrhage and should not be treated with antihistamines. (Choice E) Otolith repositioning maneuvers (eg, Epley) are used to treat benign paroxysmal positional vertigo (BPPV). In contrast to this patient's condition, BPPV does not cause headache but affects the semicircular canals and therefore has characteristics of peripheral vertigo. Epley Educational objective: Central vertigo presents with nonfatigable nystagmus, which cannot be suppressed by visual fixation. Head imaging should be performed to evaluate for cerebellar stroke or hemorrhage in patients who have persistent, new-onset central vertigo and vascular risk factors, neurologic signs/symptoms, or accompanying headache. References: Stroke among patients with dizziness, vertigo, and imbalance in the emergency department: a population-based study. (http://www.ncbi.nlm.nih.gov/pubmed/16946161) Differentiating between peripheral and central causes of vertigo. (http://www.ncbi.nlm.nih.gov/pubmed/9674515)

A 64-Year-Old Woman Is Brought to the Emergency Department Due