From the Guidelines
Vertigo after a stroke should be initially evaluated with imaging, particularly when there are abnormal neurologic examination findings or a HINTS examination consistent with central vertigo, as approximately 25% of acute vestibular syndrome (AVS) cases are caused by stroke. When managing post-stroke vertigo, it's crucial to consider the potential for severe and debilitating consequences, especially in cases involving posterior circulation strokes of the brainstem and cerebellum 1. Key considerations in management include:
- Vestibular rehabilitation therapy (VRT) exercises to help retrain the brain and compensate for balance issues
- Symptomatic relief with medications such as betahistine or meclizine
- Short-term use of diazepam for severe cases, with caution due to dependency risks
- Environmental modifications and lifestyle adjustments to minimize symptoms and prevent falls The brain's ability to develop compensatory mechanisms over time can lead to improvement in symptoms, but persistent or worsening vertigo requires immediate medical attention to rule out new strokes or other complications 1. In clinical practice, prioritizing the evaluation and management of post-stroke vertigo is essential to improve quality of life and reduce morbidity and mortality associated with falls and other complications.
From the Research
Vertigo Post Stroke
- Vertigo is a common symptom in patients with stroke, and it can be caused by damage to the brainstem or cerebellum 2
- The treatment of vertigo post stroke often involves an eclectic approach, incorporating trials of vestibular suppressants and physical therapy 2
- Vestibular rehabilitation therapy (VRT) is an exercise-based treatment program designed to promote vestibular adaptation and substitution, and it has been shown to be effective in improving balance and gait in patients after stroke 3, 4, 5
Vestibular Rehabilitation Therapy
- VRT is indicated for any stable but poorly compensated vestibular lesion, regardless of the patient's age, the cause, and symptom duration and intensity 3
- The key exercises for VRT include head-eye movements with various body postures and activities, and maintaining balance with a reduced support base with various orientations of the head and trunk 3
- VRT has been shown to be effective in improving balance and gait in patients after stroke, particularly when provided as gaze stability exercises combined with swivel chair training and head movements 5
Effectiveness of VRT
- There is moderate certainty of evidence supporting the positive effect of VRT in improving balance and gait of patients after stroke 5
- VRT has been shown to be effective in improving the vertigo symptom scale, fall risk, balance, and emotional status in adult patients with chronic dizziness 6
- The effectiveness of VRT can be attributed to its ability to promote vestibular adaptation and substitution, and to enhance gaze stability, postural stability, and activities of daily living 3, 5