What is the most appropriate next step in management for a 72-year-old woman with intermittent dizziness, ataxic gait, vertical nystagmus, and dysmetria?

From the Guidelines

The most appropriate next step in management for this 72-year-old woman is MRI of the brain (option D). The patient's presentation with vertical nystagmus, right-sided dysmetria, and ataxic gait strongly suggests a cerebellar or brainstem pathology rather than a peripheral vestibular disorder. These neurological findings, particularly vertical nystagmus, are concerning for a central nervous system lesion such as a stroke, tumor, or other structural abnormality affecting the cerebellum or brainstem. Given her age and blood pressure of 162/84 mm Hg, she is at risk for cerebrovascular disease.

According to the study by 1, patients with acute persistent vertigo and a normal neurologic examination may still have a central cause such as infarct, and the prevalence of cerebrovascular disease in those presenting with AVS is closer to 25%. The HINTS examination can be used to distinguish AVS of benign cause from posterior circulation infarct, but in this case, the patient's symptoms and signs suggest a central cause.

The following points support the choice of MRI of the brain:

• The patient's symptoms and signs, such as vertical nystagmus and ataxic gait, are concerning for a central nervous system lesion.
• The patient is at risk for cerebrovascular disease due to her age and blood pressure.
• An MRI would provide detailed imaging of brain structures to identify the underlying cause of her symptoms.
• Other options, such as bed rest, lumbar puncture, meclizine, and particle repositioning maneuvers, are not appropriate initial steps in management.

Key considerations in this case include:

• The importance of identifying a potential central nervous system lesion, such as a stroke or tumor.
• The need for detailed imaging of brain structures to determine the underlying cause of the patient's symptoms.
• The patient's risk factors for cerebrovascular disease, including age and blood pressure.

From the FDA Drug Label

Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults. The patient's symptoms of dizziness, difficulty maintaining balance, and ataxic gait suggest a vestibular system issue, but the presence of vertical nystagmus and dysmetria may indicate a more serious condition such as a stroke or cerebellar lesion.

• The patient's symptoms do not directly point to a condition that can be treated with meclizine alone.
• Given the patient's age and symptoms, a more thorough investigation is necessary to rule out serious conditions.
• MRI of the brain is the most appropriate next step in management to evaluate the patient's symptoms and determine the underlying cause of her condition 2 2.

From the Research

Patient Presentation

The patient is a 72-year-old woman presenting with a 2-day history of mild dizziness, difficulty maintaining balance, and ataxic gait. She has not experienced fever, headache, nausea, or vomiting.

Clinical Findings

• Vertical nystagmus and dysmetria of the right hand and lower extremity
• Ataxic gait
• Alert and fully oriented
• Vital signs: temperature 37°C, pulse 72/min, respirations 16/min, blood pressure 162/84 mm Hg, oxygen saturation 98% on room air

Management Options

• The patient's symptoms suggest a possible neurological condition, and further investigation is needed to determine the cause.
• The following options are considered:
  • Bed rest for several days (A)
  • Lumbar puncture (B)
  • Meclizine therapy (C)
  • MRI of the brain (D)
  • Particle repositioning maneuver (E)

Evidence-Based Considerations

• Studies have shown that lumbar puncture and brain MRI can be useful in diagnosing and managing neurological conditions 3, 4, 5.
• However, the yield of these investigations depends on clinical judgment and the specific presentation of the patient 3.
• In this case, the patient's symptoms suggest a possible cerebellar or brainstem lesion, and an MRI of the brain may be the most appropriate next step in management.
• There is no clear evidence to support the use of meclizine therapy or particle repositioning maneuver in this scenario.
• Bed rest for several days may not be necessary, and lumbar puncture may not be the initial investigation of choice without further evidence of infection or inflammation.

Next Steps

• Consider MRI of the brain to evaluate for possible cerebellar or brainstem lesions 4, 5.
• Further evaluation and management should be guided by the results of the MRI and clinical judgment.