Can a large posterior circulation stroke result in chronic vertigo?

Can Large Posterior Circulation Stroke Result in Chronic Vertigo?

Yes, large posterior circulation strokes can definitely result in chronic vertigo, particularly when they affect vestibular pathways in the brainstem, cerebellum, or vestibular cortical areas. 1

Pathophysiology and Prevalence

Posterior circulation strokes commonly present with vertigo as a symptom. According to current evidence:

• Approximately 25% of patients with posterior circulation stroke experience isolated vestibular syndrome (vertigo or imbalance) 2
• About 11-17% of patients with isolated cerebellar infarction present with vertigo, nystagmus, and postural unsteadiness that mimics peripheral vestibular disorders 3, 4
• The prevalence of vertigo in acute cortical strokes is approximately 9% 5

Affected Structures Leading to Chronic Vertigo

Large posterior circulation strokes can cause chronic vertigo when they affect:

• Cerebellum (particularly in the territory of the posterior inferior cerebellar artery)
• Inferior or superior cerebellar peduncles
• Brainstem (especially lateral or dorsolateral medulla)
• Vestibular cortical areas (insular and parietal opercular cortices) 1, 2

Clinical Presentation and Diagnosis

When evaluating a patient with suspected chronic vertigo due to posterior circulation stroke:

• The ACR Appropriateness Criteria identifies "chronic recurrent vertigo associated with brainstem neurologic deficits" as a distinct clinical variant (Variant 5) that may be due to vertebrobasilar insufficiency (VBI) 1
• Patients may present with:
  • Vertigo (rotational or non-rotational)
  • Imbalance
  • Nystagmus
  • Additional brainstem or cerebellar signs (dysarthria, dysmetria, dysphagia, sensory/motor loss, Horner's syndrome) 1, 4

Diagnostic Approach

For patients with chronic vertigo suspected to be from posterior circulation stroke:

1. MRI head without IV contrast is the preferred initial imaging to evaluate posterior circulation infarcts 1
2. MRA or CTA of the head and neck are useful for evaluation of the vasculature 1
3. CT head without IV contrast may be appropriate as initial imaging but is less sensitive than MRI for posterior fossa lesions 1

Clinical Pearls and Pitfalls

• Important distinction: While most vertigo due to posterior circulation stroke is associated with other neurologic symptoms, small infarcts in the cerebellum or brainstem can present with isolated vertigo 3, 4
• Diagnostic challenge: Posterior fossa ischemic strokes can be difficult to detect on CT with a low sensitivity (approximately 10%) 1
• Risk of recurrence: Transient ischemic attacks presenting with dizziness or vertigo carry a high risk of recurrent events and should be aggressively managed 6
• Head impulse test: This bedside examination can help differentiate acute isolated vertigo associated with cerebellar stroke from peripheral vestibular disorders 3, 4

Management Implications

For patients with chronic vertigo due to posterior circulation stroke:

• Assess for factors that modify management, including impaired mobility or balance, CNS disorders, lack of home support, and increased risk for falling 1
• Recognize that patients with a history of stroke have higher rates of BPPV, which may complicate the clinical picture 1
• Evaluate fall risk, as dizziness and vertigo are deemed the primary etiology of falls in about 13% of cases 1

In conclusion, large posterior circulation strokes can result in chronic vertigo, particularly when they affect vestibular pathways in the brainstem, cerebellum, or vestibular cortical areas. Appropriate neuroimaging with MRI and vascular studies is essential for diagnosis and management.