Brainstem stroke preceded by transient isolated vertigo attacks

Differentiating Vestibular Migraine and Posterior Circulation Transient Ischemic Attack in the Emergency Department: An Expert Practice Review

BACKGROUND

Vestibular migraine (VM) is a subset of migraine and, as its name suggests, presents with both migrainous and vestibular symptoms. However, a more worrisome diagnosis that can present with similar features is posterior circulation transient ischemic attack (pc-TIA) presenting as episodes of isolated dizziness.

OBJECTIVES

The purpose of this article is to introduce emergency physicians to the diagnostic features of VM focusing on epidemiological context, timing and quality of symptoms that help differentiate vestibular migraine from pc-TIA.

DISCUSSION

Our comprehensive search of epidemiologic data of VM patients found that they are more likely to be younger and female than patients with pc-TIA. Traditional vascular risk factors and a recent history of head or neck trauma are more common in pc-TIA patients. The onset of dizziness is sudden in pc-TIA with symptoms often lasting less than one hour. Moreover, symptoms tend to be positive in VM versus negative in pc-TIA.

CONCLUSIONS

Medical decision making should be individualized. A new nontriggered episode of isolated dizziness or those with new transient neurological findings should be evaluated for pc-TIA. VM should be considered in younger patients who have had multiple episodes over a greater time period with other migraine-related symptoms.

Dizziness demystified

Four vestibular presentations caused by six different disorders constitute most of the neuro-otology cases seen in clinical practice. 'Acute vestibular syndrome' refers to a first-ever attack of acute, spontaneous, isolated vertigo and there are two common causes: vestibular neuritis / labyrinthitis and cerebellar infarction. Recurrent positional vertigo is most often caused by benign paroxysmal positional vertigo and less commonly is central in origin. Recurrent spontaneous vertigo has two common causes: Ménière's disease and vestibular migraine. Lastly, chronic vestibular insufficiency (imbalance) results from bilateral, or severe unilateral, peripheral vestibular impairment. These six disorders can often be diagnosed on the basis of history, examination, audiometry, and in some cases, basic vestibular function testing. Here we show that most common neuro-otological problems can be readily managed by general neurologists.

Prevalence of Stroke and Hypoperfusion in Patients With Isolated Vertigo and Vascular Risk Factors

Background and Purpose: The aim of this study was to determine the prevalence and associated factors of stroke and hypoperfusion among patients with isolated vertigo and vascular risk factors.

Methods: We studied 157 patients with isolated vertigo who had undergone multimodal magnetic resonance imaging. Magnetic resonance angiography (MRA) was used to measure the diameters of vertebrobasilar arteries and to evaluate morphologic changes to vessels. Measurements obtained included length of the basilar artery and curvature index for the vertebral artery (VA). Perfusion-weighted imaging (PWI) was performed to determine relative cerebral blood flow, relative cerebral blood volume (rCBV), time to peak (TTP), and mean transit time for two mirror regions of interest (ROIs) in each map. Regional hypoperfusion of the cerebellum was considered significant when TTP and mean transit time (MTT) were present in ≥2 adjacent slices.

Results: The prevalence of stroke in patients with isolated vertigo and vascular risk factors was 24.8% (n = 39). Visual assessment revealed cerebellar hypoperfusion in 57.6% (68/118) of non-stroke patients. Multivariate logistic regression indicated that diabetes mellitus (P = 0.049, OR = 2.758), VA stenosis or hypoplasia (P = 0.023, OR = 3.486), and relative TTP of cerebellum (P = 0.002, OR = 3.197) were independent risk factors for stroke and LVA curvature index (P = 0.026, OR = 2.049), VA stenosis and hypoplasia (P = 0.009, OR = 2.977) were independent risk factors for hypoperfusion.

Conclusions: The prevalence of stroke and hypoperfusion is higher in patients with isolated vertigo and vascular risk factors, compared with matched controls. Potential risk factors include diabetes mellitus, VA stenosis or hypoplasia, and enlarged VA curvature index.