What are the management options for dizziness caused by stroke treatment?

Management of Dizziness Caused by Stroke

For acute stroke patients presenting with dizziness, immediate focus should be on treating the underlying stroke with reperfusion therapies (IV thrombolysis and/or endovascular thrombectomy within appropriate time windows), managing cerebral edema if present, preventing complications, and initiating early mobilization once medically stable. 1

Acute Phase Management (First 48 Hours)

Immediate Stroke Treatment

• Dizziness from stroke requires the same hyperacute interventions as any stroke presentation - IV thrombolysis within 4.5 hours and/or endovascular thrombectomy within 24 hours for eligible patients with large vessel occlusion 1
• Immediate non-contrast CT brain imaging and CT angiography (extracranial and intracranial) must be performed to guide treatment decisions 1
• Supplementary oxygen should be administered if oxygen saturation is <94% to prevent worsening of ischemic brain injury 1
• Blood pressure should NOT be lowered in the prehospital or acute setting unless systolic BP <90 mm Hg (hypotensive), as elevated BP may be compensatory to maintain cerebral perfusion 1

Cerebral Edema Management (If Present)

• Brain edema typically peaks at 3-5 days post-stroke and occurs in less than 10-20% of patients 1
• Corticosteroids are NOT recommended for cerebral edema management following ischemic stroke 1
• Osmotherapy (mannitol or hypertonic saline) and hyperventilation are recommended for patients deteriorating from increased intracranial pressure 1
• Elevate head of bed 20-30 degrees to facilitate venous drainage 1
• Avoid hypo-osmolar fluids (5% dextrose in water) as they worsen edema 1
• For large cerebellar infarctions causing brainstem compression and hydrocephalus, surgical decompression and evacuation is recommended 1

Seizure Management

• New-onset seizures should be treated with short-acting medications (lorazepam IV) if not self-limiting 1
• A single self-limiting seizure within 24 hours of stroke onset should NOT be treated with long-term anticonvulsants 1
• Prophylactic anticonvulsants are NOT recommended and may negatively affect neurological recovery 1

Subacute and Chronic Phase Management

Early Mobilization and Rehabilitation

• Frequent, brief out-of-bed activity involving active sitting, standing, and walking should begin within 24 hours of stroke onset if there are no contraindications 1
• Initial rehabilitation assessment by rehabilitation professionals should occur within 48 hours of admission 1
• For patients with persistent dizziness after stroke, vestibular rehabilitation exercises adapted to individual needs may be beneficial, though evidence is limited 2

Pharmacological Options for Chronic Post-Stroke Dizziness

• Cilostazol (200 mg/day) is more effective than aspirin (100 mg/day) for improving chronic dizziness following supratentorial ischemic stroke 3
• Cilostazol improves cerebral blood flow and enhances cerebral control over brainstem reflexes related to balance 3
• This applies specifically to patients 1-6 months post-stroke with persistent dizziness without other obvious sequelae 3

Spasticity Management (If Contributing to Dizziness/Imbalance)

• Begin with positioning, passive stretching, and range of motion exercises several times daily 1
• Tizanidine or oral baclofen can be used for spasticity-related symptoms in chronic stroke patients 1
• Diazepam and other benzodiazepines should NOT be used during stroke recovery due to deleterious effects on recovery and sedation 1
• Botulinum toxin or phenol/alcohol injections for selected patients with disabling spasticity 1

Supportive Care Measures

Venous Thromboembolism Prophylaxis

• Pharmacological VTE prophylaxis (low molecular weight heparin or unfractionated heparin for renal failure) should be initiated for immobile patients 1
• Early mobilization and adequate hydration help prevent VTE 1

Temperature Management

• Monitor temperature every 4 hours for first 48 hours 1
• For temperature >37.5°C, investigate for infection (pneumonia, UTI) and initiate antipyretic therapy 1

Nutrition and Swallowing

• Patients should remain NPO until swallowing screen is completed using a validated tool 1
• Swallowing screening should ideally occur on day of admission 1

Important Clinical Distinctions

Central vs. Peripheral Vertigo

• Dizziness from stroke (central vertigo) must be distinguished from benign peripheral causes using the HINTS examination (head impulse, nystagmus, test of skew) 4, 5
• Central HINTS signs include: normal head-impulse test, direction-changing gaze-evoked nystagmus, or pronounced skew deviation 5
• Vascular vertigo should be suspected with acute vestibular symptoms plus additional central neurological signs, particularly with vascular risk factors 5

Prognosis

• The risk of subsequent stroke is LOW (0.8%) when the presenting symptom is isolated dizziness diagnosed as TIA, compared to 2.9% with focal neurological deficits 6
• However, acute dizziness with stroke requires the same urgent evaluation and treatment as any stroke presentation 1

Common Pitfalls to Avoid

• Do not delay reperfusion therapy to treat dizziness symptomatically - treat the underlying stroke first 1
• Do not use corticosteroids for cerebral edema in ischemic stroke 1
• Do not lower blood pressure aggressively in acute stroke patients with dizziness, as this may worsen cerebral perfusion 1
• Do not prescribe benzodiazepines for dizziness during stroke recovery 1
• Do not use prophylactic anticonvulsants 1
• Do not dismiss isolated dizziness in high-risk patients, but recognize that stroke risk after isolated dizziness TIA is lower than with focal deficits 6