Classic Meniere’s triad of symptoms: episodic vertigo (a true spinning sensation that has an onset and an offset), sensorineural hearing loss and tinnitus
Perilymphatic fistula: infrequent complication of head injury, barotrauma, or heavy lifting in which a fistula develops at the otic capsule, permitting a transfer of pressure changes to the macular and cupular receptors. This explains the clinical syndrome of episodic vertigo and/or hearing loss provoked by sneezing, lifting, straining, coughing, and loud sounds. The latter, so-called Tullio phenomenon, occurs because sound-induced pressure waves are abnormally distributed through the inner ear. -The diagnosis is difficult as clinical tests are insensitive. Computed tomography (CT) scanning may show fluid in the region of the round window recess. Treatment with bed rest, head elevation, and avoidance of straining is the first step; failure to resolve after several weeks of conservative therapy is an indication to consider a surgical patch. Recurrences occur in 10 percent.
Semicircular canal dehiscence syndrome — In semicircular canal dehiscence syndrome, the bone overlying the superior aspect of the superior semicircular canal becomes thin or even absent, thereby allowing pressure to be transmitted to the inner ear. Vertigo is provoked by coughing, sneezing, and Valsalva maneuver. Patients may experience nausea and instability during brief episodes of vertigo. Diagnosis by MRI or high resolution CT of the temporal bone. Some patients benefit by surgical repair of their anatomical deficit.
Cogan’s syndrome: autoimmune condition that can cause interstitial keratitis and vestibuloauditory dysfunction. -Patients have Meniere's-like attacks consisting of vertigo, ataxia, nausea, vomiting, tinnitus, and hearing loss. Vestibular dysfunction may also cause oscillopsia, which is the perception of objects jiggling back and forth after abruptly turning the head to one side or the other. Caloric testing often reveals absent vestibular function. -Systemic steroids and other immunosuppressants may be required
Wallenberg’s or lateral medullary syndrome
Chiari malformation: congenital anomaly in which the cerebellar tonsils extend below the foramen magnum. This is usually asymptomatic but may be associated with a constellation of neurologic deficits (headache or neck pain, weakness with long tract signs, dysphagia, and other lower cranial nerve impairments) . Vertigo and gait imbalance are common complaints in symptomatic individuals and may represent cerebellar or brainstem pathology -when present, vertigo is often positionally induced, particularly by neck extension, perhaps manifesting pressure on brainstem and cerebellar structures or their blood supply . Vertiginous symptoms are generally mild and often resolve when the patient alters his or her head position. Downbeating nystagmus is often associated with this syndrome, but other patterns of central nystagmus may be seen as well. The diagnosis is confirmed with sagittal MRI. -Surgical decompression may be required to relieve symptoms and is usually successful
Episodic ataxia type 2 (EA-2): autosomal dominant condition caused by mutations in a brain-specific P/Q type calcium channel gene on chromosome 19. Attacks of severe vertigo, nausea, and vomiting, and ataxia begin in childhood or early adult life. These can last a few hours or a few days. Gaze-evoked, rebound, or downbeat nystagmus may be evident not only during but also between attacks. The attacks respond to acetazolamide in a dose of 250 to 750 mg/day
CT head without contrast: Bilateral ischemic infarcts of the cerebellar hemispheres R>L without significant compression of the 4th ventricle
CTA of head and neck: 1. Nonvisualization of both posterior inferior cerebellar arteries in this patient with acute/subacute bilateral cerebellar infarcts. Nonvisualization of the vessels maybe due to thrombus/occlusion of the vessels versus less likely nonvisualization due to small size. 2. No dissection. 3. Mild atherosclerotic narrowing of the right V4 segment. 4. No hemodynamically significant stenosis of the proximal cervical internal carotid arteries. 5. Limited study. 6. Right vertebral artery is slightly smaller than the left throughout the neck. Intracranially, the right vertebral artery Becomes diminutive. These findings likely congenital. Origin of the left vertebral artery which is dominant and not optimally visualized due to artifact from high density venous contrast
Causes of bilateral cerebellar ischemia to be discussed, but he has FV Leiden mutation, obesity, mild atherosclerosis, hypertension, congenital ?dominant L vertebral artery. Plans aspirin, anticoagulation, LMWH, Causes of his hypertension needs to be further investigated. Cushings vs primary aldosteronism vs salt intake vs ?r/o licorice intake. Check plasma renin & aldosterone to r/o primary aldosteronism (both have diurnal variation. Highest in early morning)
Patient is on full strength aspirin, low dose statin, previously only on prophylactic anticoagulation
There is little evidence that aspirin has a significant effect on the prevention of VENOUS thromboembolic events in medical patients.
LMWH vs UFH study from 2009 Cochrane database: In a meta-analysis of randomized trials comparing the use of UFH versus LMW heparin for the prevention of VTE in medical patients, there was no statistically significant difference in efficacy between the two types of heparin preparations . However, there was a significant 72 percent risk reduction in major bleeding when LMW heparin was compared with UFH (RR 0.28; 95% CI 0.10-0.78).
Hong JM, Bang OY, Chung CS, Joo IS, Huh K. Frequency and clinical significance of acute bilateral cerebellar infarcts. Cerebrovasc Dis. 2008;26(5):541-8. Epub 2008 Oct 6. Department of Neurology, Ajou University School of Medicine, Suwon, South Korea.
Baseline demographics were not significantly different between unilateral cerebellar infarction (UCI) and bilateral cerebellar infarction (BCI), except for initial stroke severity (modified NIH Stroke Scale and infarct volume) and diabetes. Large-artery atherosclerosis was significantly higher in BCI, whereas undetermined causes were higher in UCI (p = 0.028). By multiple regression analysis, BCI was the only independent radiological factor for poor prognosis (odds ratio, 6.96; 95% CI, 1.80-26.92), and represented a significantly more unstable hospital course, longer hospital stay, worse mRS at discharge, and higher mortality.
Neurology Morning Report
Neurology Morning Report
Cathy Larrain, MD, PGY3
August 3, 2010
41 year-old male with no known past
medical history presents with acute
onset vertigo and nausea that awoke
him from sleep @4am
He initially walked without difficulty to
the bathroom where he vomited 3-4
times bilious emesis and continued to
experience transient dizziness and
vertigo for a few hours
He denied tinnitus, ear pain, visual or
He described recent recovery from
cold-like symptoms 4 days prior to
symptom onset with cough, sore
throat, runny nose which resolved
after few days of “cold medicine”
He did not experience further
symptoms for the rest of the day apart
from headache frontal and occipital
locations, dull, 4/10, for which he took
aspirin with relief.
The following morning he had trouble
swallowing. Family members grew
concerned that he appeared short of breath.
He denied shortness of breath or chest pain
but said talking was cumbersome because of
his difficulty swallowing.
He reported intermittent diplopia exacerbated
by looking at far objects with alternating
blurry vision, then developed persistent right
hand numbness and could not walk because
the sensation of the room tilting to the right.
No known past medical history, generally
◦ Had not seen a physician in 15 years
◦ Never hospitalized
No surgical history
All childhood immunizations up to date
No known drug allergies
Home Medications: occasional Tums &
He denied smoking and illicit drug use,
admitted to rare 2x/yr alcohol use
Employed as a salesman for
◦ “on my feet 8 hours a day”
Family History (+)vertigo
He fell backward slightly while
ambulating, could not stand because
of sensation of room and body tilting
T-97.1 BP-188/96 HR-84 RR-20 SpO2-100% RA Glc-140
Morbidly obese gentleman with eyes closed in moderate emotional
Skin intact, no rash, clammy
Horizontal nystagmus gazing to the left not suppressed with visual
fixation, diplopia R>L, motor dysmetria of the RUE, 5/5 strength
bilaterally UE/LE, ? Babinski on right
No palpable lymphadenopathy
Facial symmetry, +ptosis, normocephalic, atraumatic with moist
Neck musculature slightly stiff R>L without meningeal signs or
Lungs clear bilaterally throughout airfields
Heart sounds unremarkable, normal S1/S2
Abdomen obese with old striae, no stigmata of liver disease, no
tenderness or organomegaly, normoactive bowel sounds
Extremities without clubbing, cyanosis, edema
◦ alone or with other antiplatelet drugs, is highly
effective in reducing major ARTERIAL thrombotic
events in patients who are at risk or who have
established atherosclerotic disease.
LMWH vs UFH
◦ In a meta-analysis of randomized trials comparing the
use of UFH versus LMW heparin for the prevention of
VTE in medical patients, there was no statistically
significant difference in efficacy between the two
types of heparin preparations. However, there was a
significant 72 percent risk reduction in major bleeding
when LMW heparin was compared with UFH (RR
0.28; 95% CI 0.10-0.78).
The JUPITER study was randomized, double-blind, placebo-
controlled, multicenter trial of rosuvastatin for the prevention
of VTE in men ≥50 years of age and women ≥60 years of age
without history of cardiovascular disease, LDL <130 mg/dL
and high-sensitivity CRP ≥2.0 mg/L.
In this study, 17,802 apparently healthy subjects were
randomly assigned in a 1:1 ratio to treatment with oral
rosuvastatin (20 mg/day) or a matching placebo. At a median
follow-up of 1.9 years (maximum: 5 years), the following
results were obtained:
◦ Symptomatic VTE occurred in 94 participants: 34 in the
rosuvastatin group and 60 in the placebo group, for VTE rates of 0.18 and
0.32 events/100 person-years of follow-up, respectively (hazard ratio with
rosuvastatin 0.57; 95% CI 0.37-0.86).
◦ Hazard ratios for the use of rosuvastatin for unprovoked VTE, provoked
VTE, pulmonary embolism, and DVT were similarly significant at 0.61,
0.52, 0.77, and 0.45, respectively.
◦ The use of rosuvastatin significantly reduced the composite end point of
first cardiovascular event, VTE, or death (hazard ratio 0.66; 95% CI 0.57-
0.76). The number of patients needed to treat for 4 or 5 years to prevent
one of these events was 23 and 18, respectively.
◦ Consistent effects were observed in all of the subgroups examined. No
differences in the rates of bleeding were noted between the two treatment
In a second population-based case control study, an analysis
restricted to persons without a history of cardiovascular
events indicated that the current use of statins significantly
reduced the incidence of VTE (adjusted relative risk 0.75;
95% CI 0.61-0.91)
Vertigo is the predominant symptom
that arises from an acute asymmetry
of the vestibular system, which
◦ vestibular apparatus in the inner ear
◦ vestibular nerve and nucleus within the
◦ connections to and from the vestibular
portions of the cerebellum
Evaluation of Vertigo
Identifying likely etiologies
◦ Peripheral vestibular dysfunction (40%)
◦ Central brainstem vestibular lesion (10%)
◦ Psychiatric disorder (15%)
◦ Other etiologies (25%), e.g. presyncope
◦ Idiopathic (10%)
Eliciting pertinent history and physical
Positional changes in symptoms
Orthostatic blood pressure and pulse
Observation of gait
Detection of nystagmus
Ischemic strokes in the posterior circulation are caused by
atherosclerosis or embolism.
Cerebellar infarction accounts for 2% of acute strokes and in
order of frequency
◦ posterior inferior cerebellar artery (PICA) 40%
◦ superior cerebellar artery (SCA) 35%
◦ border zone infarcts 20%
◦ anterior inferior cerebellar artery (AICA) 5%
◦ posterior inferior cerebellar artery (PICA) rare
PICA arises from the intracranial vertebral artery (VA) and
◦ Lateral medullary tegmentum, inferior cerebellar peduncle, the
ipsilateral portion of the inferior vermis and the inferior surface of
the cerebellar hemispheres. The medial branch of PICA supplies
the medial cerebellum and the dorsal medulla oblongata, and the
lateral branch supplies the inferoposterolateral aspect of the
The clinical presentation of acute cerebellar
infarcts depend upon involved territory involved
and the presence or absence of forth ventricular /
Presentation of sudden onset of occipital
headache, severe vertigo, nausea, vomiting, ataxia
of gait and trunk, ipsilateral axial lateropulsion,
dysarthria and impairment of consciousness.
Brainstem compression results in increasing
headache, decreased level of alertness, head tilt
and tonsillar herniation through the foramen
These infarcts usually involve PICA, AICA or both.
Cerebellar infarction in the territory of
posterior inferior cerebellar artery (PICA) is
usually unilateral, as the origin of PICA
arises from a single vertebral artery (VA).
Very few patients with acute bilateral
cerebellar infarcts in the territory of PICA
have been described in literature to date.
Different hypotheses have been put forth
to explain the pathogenesis of bilateral
cerebellar infarcts in the PICA territory:
1. Both PICAs arising from an occluded
2. Branches to both PICA regions arising from
3. Pressure effect caused by a large PICA
4. Hemodynamic mechanism with
hypoperfusion in the most peripheral
5. Double, simultaneous embolic stroke
PICA is the most variable cerebellar artery.
It is absent in 20% of VA angiogram; in the
majority of these instances, the AICA
supplies the PICA territory.
In cases when both PICAs are
asymmetrical, branches of one PICA
partially feed the territory of the other.
Furthermore, an "extensive“ PICA may
supply the cerebellum bilaterally
Secondary prevention of VTE: aspirin, UFH vs LMWH, statin
◦ Warfarin is not appropriate for immediate and short-term
prevention of VTE in medical patients
When evaluating for a patient with vertigo and/or dizziness,
localize the symptoms/type/timing to help identify etiology
◦ Peripheral: ear pain, tinnitus, abnormal hearing
◦ Central: numbness, weakness, gait impairment, diplopia,
Life threatening causes of vertigo include brainstem ischemia
and cerebellar infarction or hemorrhage
◦ Cerebellar strokes comprise 2% of acute strokes
Symptoms of acute cerebellar stroke include sudden onset of
occipital headache, severe vertigo, nausea, vomiting, ataxia
of gait and trunk, ipsilateral axial lateropulsion, dysarthria and
impairment of consciousness.
◦ Keep in mind the concern for brainstem compression and
worsening mental status
Ischemic strokes in the posterior circulation are caused
by atherosclerosis or embolism (of a dominant PICA).
Cerebellar infarction in the territory of PICA is usually
unilateral with very few bilateral infarcts described in
literature thus far
Bilateral cerebellar infarction is hypothesized to occur
◦ Both PICAs arising from an occluded basilar artery or other
◦ Branches to both PICA regions arising from one side
◦ Pressure effect caused by a large PICA infarct
◦ Hemodynamic mechanism with hypoperfusion in the most
peripheral branches; and
◦ Double, simultaneous embolic stroke
Siddiqui M, Khan FS, Salman M. Bilateral
cerebellar stroke with good functional recovery: a
case report. Pak J Neurol Sci. 2009; 4(2): 71-73.