What is the best approach to manage dizziness in a post-stroke patient?

Treatment of Dizziness in Post-Stroke Patients

For post-stroke patients with dizziness, begin with early mobilization within 24-48 hours if medically stable, assess for vestibular dysfunction versus central causes, and consider cilostazol over aspirin for chronic persistent dizziness in the absence of contraindications. 1, 2

Initial Assessment and Timing Considerations

• Determine the timing of dizziness onset relative to stroke, as this fundamentally changes management: dizziness within 24 hours may represent acute vestibular syndrome requiring urgent evaluation for posterior circulation involvement, while chronic dizziness (>1-6 months post-stroke) represents a different therapeutic target 1, 3, 4

• Assess whether dizziness is rotational vertigo versus non-rotational dizziness, as the 2011 ASA/ACCF/AHA guidelines note that vertigo was associated with subsequent stroke risk in population studies, though non-rotational dizziness has less established causative relationship to extracranial vascular disease 1

• Rule out severe orthostatic hypotension before mobilization, particularly measuring blood pressure lying and sitting; cancel mobilization if systolic BP decreases >30 mmHg with concurrent symptoms, especially in patients on beta-blockers or with hypovolemia 1

Early Mobilization Protocol (First 48 Hours)

• Begin frequent, brief out-of-bed activity involving active sitting, standing, and walking within 24 hours of stroke onset if no contraindications exist, as recommended by the 2018 Canadian Stroke Best Practice guidelines, though more intense early sessions provide no additional benefit 1

• Contraindications to early mobilization include: arterial puncture for interventional procedures, unstable medical conditions, low oxygen saturation, lower limb fracture, and severe dizziness with systolic BP drop >30 mmHg on position change 1

• Monitor temperature every 4 hours for the first 48 hours, as fever >37.5°C worsens outcomes and may indicate infection requiring investigation and treatment 1

Vestibular and Oculomotor Evaluation

• Request evaluation by rehabilitation professionals within 48 hours of admission to assess vestibular function, as the 2016 AHA/ASA guidelines recommend initial screening and assessment by rehabilitation professionals in direct contact with the patient 1

• Visual complaints occur in 56% of post-stroke patients with dizziness and correlate with abnormalities in oculomotor and caloric testing, being more frequent in vertebrobasilar system strokes with oscillopsia and reduced visual acuity 5

• Vestibular rehabilitation therapy should begin as early as possible once the patient is medically able to participate in active rehabilitation, as emphasized by the 2018 Canadian guidelines 1

Pharmacological Management for Chronic Dizziness

For chronic dizziness persisting 1-6 months after supratentorial ischemic stroke without other obvious sequelae, cilostazol 200 mg/day is superior to aspirin 100 mg/day in a prospective randomized trial showing significant improvement (P<0.0001) through increased supratentorial cerebral blood flow and improved fixation suppression of the vestibulo-ocular reflex 2

• Meclizine is FDA-approved for vertigo associated with vestibular system diseases and may be considered for symptomatic relief in appropriate cases, though evidence specific to post-stroke dizziness is limited 6

• Avoid neuroleptics, benzodiazepines, phenobarbital, and phenytoin during stroke recovery, as the 2005 VA/DoD guidelines recommend against these agents due to potential adverse effects on neurological recovery 1

Diagnostic Workup Based on Clinical Presentation

• For isolated vertigo or non-rotational dizziness without focal neurological signs, the pathophysiological mechanism and relationship to extracranial carotid/vertebral disease has not been fully elucidated, requiring careful evaluation to exclude high-grade stenosis 1

• When dizziness presents as acute vestibular syndrome (38.8% of posterior circulation strokes), use the HINTS bedside examination protocol (Head Impulse, Nystagmus, Test of Skew) which demonstrates 100% sensitivity for central nervous system causality when performed by trained clinicians 3

• Brain CT has only 27% sensitivity for posterior circulation stroke, so do not rely on negative CT to exclude stroke in patients with acute vestibular syndrome; MRI remains the gold standard 3

Common Pitfalls to Avoid

• Do not assume all post-stroke dizziness is benign peripheral vestibular dysfunction—dizziness is the most common symptom of posterior circulation TIA and carries high risk of recurrent events requiring aggressive medical management 4

• Do not delay mobilization excessively due to dizziness alone—the 2016 AHA/ASA guidelines emphasize that rehabilitation therapy should begin as early as medically possible, with clinical judgment guiding intensity 1

• Do not overlook depression as a contributing factor—assess for mood disorders using structured inventories, as depression can delay ADL recovery and reduce social functioning, though depression itself does not directly cause dizziness 1

Long-Term Management and Follow-Up

• Ensure adequate hydration and encourage regular aerobic exercise as part of secondary stroke prevention, which improves functional ability, walking endurance, and balance 1

• Screen for cognitive impairment using validated brief instruments (Mini-Mental State Examination or Montreal Cognitive Assessment) during the first year, as cognitive deficits may compound balance and spatial orientation problems 1

• Link patients to community exercise programs through structured assessment, counseling, and referral, targeting 150 minutes per week of moderate activity or 75 minutes per week of vigorous activity when achievable 1