What is the management of giddiness in brainstem infarct?

Management of Giddiness in Brainstem Infarct

For giddiness in brainstem infarct, prioritize close neurological monitoring for signs of deterioration, elevate the head of bed 20-30 degrees, and consider osmotic therapy (mannitol or hypertonic saline) if clinical deterioration occurs from cerebral swelling. 1, 2, 3

Immediate Assessment and Monitoring

Frequent monitoring is essential as giddiness may herald deterioration from brainstem compression or cerebellar edema 4, 1:

• Monitor level of consciousness continuously - decreased alertness is the most reliable sign of tissue swelling 2
• Check for new brainstem signs: pupillary changes (anisocoria, pinpoint pupils), loss of oculocephalic responses, abnormal eye movements 4, 1, 2
• Watch for respiratory changes: irregular breathing patterns, bradycardia, or sudden apnea indicate further brainstem compression 4, 1
• Track Glasgow Coma Scale: deterioration defined as GCS <12 on admission or decline ≥2 points 4, 1, 2
• Obtain imaging if deterioration suspected: look for fourth ventricular compression and hydrocephalus 4, 1, 2

Critical caveat: Initial CT can be normal in up to 25% of cerebellar infarctions, and MRI may be normal even with classic brainstem syndromes 2, 5. Clinical diagnosis based on alternating syndromes (Wallenberg, Weber, Millard-Gubler) remains paramount 5.

Initial Medical Management

Transfer to ICU or stroke unit immediately for comprehensive monitoring and treatment 1:

Positioning and Basic Measures

• Elevate head of bed 20-30 degrees to improve venous drainage and reduce intracranial pressure 1, 3
• Ensure adequate oxygenation and avoid hypoxia, hypercarbia, and hyperthermia 3
• Keep patient NPO initially to prevent aspiration 1

Fluid and Metabolic Management

• Restrict free water and avoid hypo-osmolar fluids (especially 5% dextrose) which worsen cerebral edema 1, 3
• Maintain normoglycemia (glucose <8 mmol/L) 1
• Use isotonic fluids to correct hypovolemia 1

Osmotic Therapy for Clinical Deterioration

If patient deteriorates from cerebral swelling, osmotic therapy is reasonable (Class IIa, Level C) 4, 1:

• Mannitol: 0.25-0.5 g/kg IV over 20 minutes every 6 hours (maximum 2 g/kg), or 1 g/kg of 20% solution 4, 3
• Hypertonic saline: 3% sodium chloride or 0.686 mL/kg of 23.4% saline (equiosmolar to mannitol) 4, 3
• Mechanism: Creates osmotic gradient drawing water from neurons into arteries, causing vasoconstriction and reduced cerebrovascular volume 4

Important limitation: Despite osmotic therapy, mortality remains 50-70% in patients with increased ICP, so these are temporizing measures 3

Thromboprophylaxis

• Initiate subcutaneous heparin, low molecular weight heparin, or heparinoids for DVT prevention 1
• Avoid IV heparin due to hemorrhagic transformation risk 1
• Consider continuing aspirin alone but typically suspend dual antiplatelet therapy (aspirin + clopidogrel) 1

What NOT to Use

Do not use hypothermia, barbiturates, or corticosteroids - insufficient data and not recommended (Class III, Level C) 4, 1. No evidence shows that hyperventilation, corticosteroids, diuretics, mannitol, or glycerol alone improve outcomes in ischemic brain swelling 3.

Surgical Consultation

Obtain early neurosurgical consultation for potential decompressive surgery 1:

• For cerebellar infarct with deterioration: perform suboccipital craniectomy with dural expansion 1
• If hydrocephalus present: ventriculostomy must be accompanied by suboccipital decompression to avoid upward cerebellar herniation 1
• Timing consideration: peak swelling typically occurs several days after ischemia onset 2
• Prognosis: surgery after cerebellar infarction leads to acceptable functional outcomes in most patients 1

Symptomatic Treatment of Giddiness

While addressing the underlying pathophysiology, symptomatic management of vertigo/dizziness may include 6:

• Vestibular suppressants (anticholinergics, benzodiazepines) for acute severe vertigo - but use briefly to avoid delaying compensation 6
• Physical therapy/vestibular rehabilitation once stable to promote compensation 6

Research suggests autonomic dysfunction contributes to persistent dizziness in brainstem infarcts 7. One study showed cilostazol (200mg/day) superior to aspirin for chronic post-stroke dizziness by improving supratentorial cerebral blood flow and fixation suppression of vestibulo-ocular reflex 8, though this applies to chronic phase (1-6 months post-stroke) rather than acute management.

Monitoring Duration

Patients with territorial cerebellar infarctions require monitoring up to 5 days, even if initially stable 2, as deterioration can occur days after initial presentation when edema peaks 2.