How to manage a patient with stroke associated with ongoing vertigo?

Management of Stroke Associated with Ongoing Vertigo

Patients with stroke presenting with ongoing vertigo require urgent neuroimaging with MRI (preferably) rather than CT, along with aggressive medical management including antiplatelet therapy, and should be evaluated for posterior circulation involvement using the HINTS examination.

Diagnostic Approach

Initial Assessment

• Distinguish between peripheral and central causes of vertigo, as stroke (particularly posterior circulation stroke) is a dangerous cause of acute vestibular syndrome (AVS) that requires immediate intervention 1
• Prevalence of cerebrovascular disease in patients presenting with AVS is approximately 25% and may be as high as 75% in high vascular risk cohorts 1
• Focal neurologic symptoms/signs may be lacking in one-third to two-thirds of patients with stroke-related vertigo 1

Key Clinical Features Suggesting Stroke

• Presence of gait instability as a presenting complaint (significantly increases odds of stroke) 2
• Subtle neurologic findings even with otherwise normal examination 2
• Nystagmus patterns suggesting central cause: downbeating nystagmus, direction-changing nystagmus without head position changes, gaze-holding nystagmus, or baseline nystagmus without provocative maneuvers 1
• Associated symptoms such as headache, nausea, vomiting, and ataxia 3
• Failure to respond to standard vestibular treatments 1

HINTS Examination

• Head-Impulse, Nystagmus, Test-of-Skew (HINTS) examination should be performed to distinguish between peripheral and central vertigo 1
• When performed by specially trained practitioners, HINTS is more sensitive than early MRI for detecting stroke (100% versus 46%) 1
• A negative HINTS examination (consistent with peripheral vertigo) performed by experts has high negative predictive value for stroke 1

Imaging

Recommended Imaging

• MRI is superior to CT for diagnosis of acute stroke in patients with vertigo 2
• Head CT is inadequate for diagnosing acute stroke in patients with vertigo (multiple studies show CT may miss strokes in the posterior circulation) 1, 2
• Imaging should include evaluation of both intracranial and extracranial vertebral arteries and basilar artery 4

Treatment Approach

Acute Management

• Meclizine can be used for symptomatic management of vertigo at doses of 25 mg to 100 mg daily in divided doses 5
• Caution patients about drowsiness with meclizine and advise against driving or operating dangerous machinery 5
• Avoid concurrent use of alcohol or other CNS depressants with meclizine 5

Stroke-Specific Management

• Implement aggressive medical management with antiplatelet therapy 4
• Initiate statin therapy regardless of baseline cholesterol levels 4
• Implement comprehensive vascular risk factor modification 4
• Consider admission for observation in patients with acute vertigo when stroke is suspected 6

Special Considerations

Risk Assessment

• Assess patients for factors that modify management, including impaired mobility or balance, CNS disorders, lack of home support, and increased risk for falling 1
• Elderly patients with vertigo have a 12-fold increase in the risk for falls 1
• Falls risk screening should be performed, particularly in elderly patients 1

Anatomical Considerations

• Vertigo is most strongly associated with cerebellar involvement (5.59 times higher odds) 3
• Other common locations include medulla, pons, and basilar artery territory 3
• 80% of stroke patients with vertigo have posterior circulation involvement 7
• Absence of nystagmus does not rule out stroke - nystagmus may be absent in up to 46% of posterior circulation strokes 7

Prognosis

• Vertigo in stroke is not associated with increased in-hospital mortality or poor prognosis at hospital discharge 3
• However, posterior circulation TIAs presenting with dizziness/vertigo carry a high risk of recurrent events 4

Pitfalls to Avoid

• Do not rely solely on CT imaging, as it frequently misses posterior circulation strokes 2
• Do not assume absence of focal neurologic deficits rules out stroke, as up to 80% of patients with stroke-related AVS may have no associated focal neurologic deficits 1
• Do not dismiss episodic vestibular symptoms, as approximately 5% of stroke patients present with episodic rather than continuous vestibular syndrome 7
• Do not overlook subtle neurologic findings, which significantly increase the odds of stroke 2