How to manage persistent giddiness in patients 10 days after a brainstem infarct?

Management of Persistent Giddiness 10 Days After Brainstem Infarct

For persistent dizziness at 10 days post-brainstem infarct, continue close monitoring for signs of deterioration while initiating vestibular rehabilitation and treating any autonomic dysfunction, as the symptom may reflect mild autonomic impairment rather than acute deterioration. 1

Initial Assessment at Day 10

At 10 days post-infarct, you must distinguish between three scenarios:

• Stable persistent symptoms - Most likely representing residual vestibular dysfunction or autonomic impairment 1
• Clinical deterioration - Declining Glasgow Coma Scale (≥2 points drop), new brainstem signs, or decreased level of consciousness 2, 3
• Delayed swelling - Though peak swelling typically occurs at 3-5 days, territorial cerebellar infarctions require monitoring up to 5 days, and some patients may show delayed progression 3, 4

Critical Red Flags Requiring Immediate Intervention

Monitor specifically for these signs of deterioration that warrant urgent neurosurgical consultation:

• Pupillary changes: anisocoria, pinpoint pupils, or midposition pupils 2, 3
• Loss of oculocephalic responses 2, 3
• Decreased level of consciousness - the most reliable sign of tissue swelling 3
• Respiratory irregularities: bradycardia, irregular breathing patterns, or sudden apnea 2, 3
• New motor deficits or worsening coordination 2

If any of these develop, obtain urgent neuroimaging and neurosurgical consultation for potential suboccipital decompressive craniectomy 4.

Management of Stable Persistent Dizziness

Autonomic Dysfunction Assessment

Persistent dizziness at 10 days often reflects mild autonomic dysfunction rather than structural progression. 1

• Patients with brainstem infarction commonly experience vertigo, floating sensation, and general fatigue during standing due to impaired blood pressure regulation 1
• Consider formal autonomic testing if symptoms persist, looking for reduced mean blood pressure response to head-up tilt and impaired heart rate variability 1
• The composite autonomic scoring scale (CASS) can quantify mild autonomic dysfunction that may not be apparent on standard neurological examination 1

Symptomatic Management

Vestibular rehabilitation should be initiated for persistent dizziness in stable patients. 2, 5

• Early mobilization with measures to prevent subacute complications is strongly recommended 2
• Ataxia is present in 86% of brainstem stroke rehabilitation patients and requires targeted therapy 5
• Avoid prolonged bed rest, which can worsen orthostatic symptoms 2

Medical Optimization

Continue standard stroke care measures:

• Maintain normoglycemia (glucose <8 mmol/L or <144 mg/dL) 2, 4
• Treat any fever (>37.5°C) aggressively, as hyperthermia worsens outcomes 2
• Ensure adequate hydration with isotonic fluids to correct hypovolemia 4
• Continue thromboembolic prophylaxis with subcutaneous heparin or low molecular weight heparin 4

Imaging Considerations

Normal MRI does not exclude brainstem infarction, particularly in midbrain and caudal pontine lesions. 6

• In one series, 27% (8/30) of patients with classical brainstem syndromes persisting >10 days had normal MRI 6
• If clinical suspicion remains high despite normal initial imaging, the diagnosis should be based on clinical and electrophysiological criteria 6
• Repeat imaging is warranted only if new deterioration occurs 2

Common Pitfalls to Avoid

• Do not assume persistent dizziness at 10 days indicates deterioration - it more likely represents residual vestibular or autonomic dysfunction 1
• Do not use corticosteroids, barbiturates, or hypothermia for persistent symptoms without acute deterioration, as there is insufficient evidence for benefit 2, 4
• Do not overlook autonomic dysfunction as a treatable cause of persistent dizziness 1
• Do not discharge without ensuring adequate monitoring - even initially stable territorial cerebellar infarctions can deteriorate up to 5 days 3, 4

Expected Clinical Course

Patients with brainstem infarction and normal MRI typically have favorable outcomes, with symptoms disappearing within a few weeks 6. The presence of persistent dizziness at 10 days without deterioration suggests a benign course, though continued monitoring and rehabilitation remain essential 1, 6.