Assessment and Plan
Assessment
This 54-year-old male with hypertension, diabetes mellitus, and chronic kidney disease presenting with acute rotatory vertigo, bilateral lower-extremity weakness, chills, and mild headache requires urgent evaluation to exclude posterior circulation stroke, despite a completely normal neurological examination.
The clinical presentation raises significant concern for a hypertensive emergency with potential posterior circulation ischemia versus a peripheral vestibular disorder. The combination of rotatory vertigo, bilateral leg weakness (even if now resolved), and vascular risk factors (HTN, DM, CKD) mandates aggressive evaluation for stroke, as focal neurologic symptoms may be lacking in one-third to two-thirds of patients with stroke-related vertigo 1.
Key Diagnostic Considerations:
Posterior circulation stroke/TIA – The triad of acute rotatory vertigo, bilateral lower-extremity weakness, and multiple vascular risk factors (HTN, DM, CKD) is highly concerning for vertebrobasilar insufficiency or cerebellar stroke, even with a normal current examination 2, 1. Stroke prevalence in acute vestibular syndrome with high vascular risk can reach 75% 1.
Vestibular neuritis – Less likely given the bilateral leg weakness and multiple risk factors, though the rotatory vertigo without hearing loss fits this diagnosis 2.
Hypertensive emergency – The patient's blood pressure status is not documented in the presentation, but given his history of HTN on multiple agents (atenolol, telmisartan) and acute neurologic symptoms, hypertensive encephalopathy must be excluded 3.
Benign paroxysmal positional vertigo (BPPV) – Unlikely given the duration of symptoms (hours rather than seconds) and lack of clear positional triggers 2, 4.
Plan
1. Immediate Neurologic Assessment and Imaging
Obtain emergent MRI brain without contrast to evaluate for posterior circulation stroke or cerebellar infarction, as MRI has 46% sensitivity for early stroke detection compared to 100% sensitivity of HINTS examination when performed by trained practitioners 1, 4. CT imaging should be avoided as it frequently misses posterior circulation strokes 1.
Perform HINTS examination (Head Impulse, Nystagmus, Test of Skew) if trained personnel are available, as this has 100% sensitivity for detecting stroke in acute vestibular syndrome 1, 4. Look specifically for:
- Central nystagmus patterns (downbeating, direction-changing without head position changes, gaze-holding nystagmus) 1
- Negative head impulse test (suggests central cause)
- Vertical skew deviation (suggests central cause)
Document blood pressure carefully with orthostatic measurements, as the patient is on atenolol and telmisartan and reports dizziness on standing 2. Check for postural hypotension, which is a known complication of blood pressure-lowering drugs in CKD patients 2.
2. Blood Pressure Management
If blood pressure is >180/120 mmHg WITH acute neurologic symptoms (headache, vertigo, transient weakness), this constitutes a hypertensive emergency requiring:
- Immediate ICU admission with continuous arterial-line monitoring 3
- IV nicardipine starting at 5 mg/hr, titrated by 2.5 mg/hr every 15 minutes (max 15 mg/hr) to reduce mean arterial pressure by 20-25% in the first hour 3
- Target blood pressure of ≤160/100 mmHg over 2-6 hours if stable, then gradual normalization over 24-48 hours 3
- Avoid excessive acute drops >70 mmHg systolic, as this can precipitate cerebral, renal, or coronary ischemia in chronic hypertensives with altered autoregulation 3
If blood pressure is >180/120 mmHg WITHOUT acute target-organ damage (hypertensive urgency):
- Manage with oral antihypertensives and outpatient follow-up within 2-4 weeks 3
- Gradual reduction to <160/100 mmHg over 24-48 hours 3
If acute ischemic stroke is confirmed on imaging with BP >220/120 mmHg:
- Reduce mean arterial pressure by approximately 15% over the first hour 3
- Avoid blood pressure reduction within the first 5-7 days unless BP exceeds 220/120 mmHg 3
3. Medication Review and Adjustment
Review current antihypertensive regimen (atenolol, telmisartan):
- Inquire about postural dizziness and check for postural hypotension regularly, as recommended for CKD patients on BP-lowering drugs 2
- Consider that atenolol may contribute to bradycardia and orthostatic symptoms
- Telmisartan is appropriate for this patient with CKD, HTN, and DM, as RAS blockade is recommended for patients with diabetes, hypertension, and albuminuria 2
Monitor renal function and electrolytes closely:
- Measure serum creatinine and potassium, as RAS inhibitors can cause acute deterioration in kidney function 2
- A modest creatinine increase up to ~30% is acceptable with RAS blockade 2
4. Glycemic Control Assessment
Check fingerstick glucose immediately and review recent HbA1c, as hyperglycemia can worsen outcomes in acute stroke and hypertensive emergencies 3.
Ensure adequate fluid and caloric intake, as infection or dehydration is more likely to necessitate hospitalization in patients with diabetes 3.
5. Laboratory Evaluation
Obtain comprehensive laboratory panel:
- Complete blood count (hemoglobin, platelets) to assess for microangiopathic hemolytic anemia 3
- Basic metabolic panel (creatinine, sodium, potassium) to evaluate renal function and electrolyte abnormalities 3
- Troponin if chest pain develops 3
- Urinalysis for protein and urine sediment to identify renal damage 3
6. Vestibular Assessment (if stroke excluded)
If MRI is negative for stroke, perform Dix-Hallpike maneuver to evaluate for BPPV, looking for 5-20 second latency, torsional upbeating nystagmus toward the affected ear, and crescendo-decrescendo pattern resolving within 60 seconds 4.
If BPPV is confirmed, perform canalith repositioning procedure (Epley maneuver) immediately, which has an 80% success rate after 1-3 treatments 4.
Avoid vestibular suppressants (meclizine, diazepam) for BPPV, as they prevent central compensation and delay recovery 4.
7. Disposition and Follow-Up
Admit to hospital if:
- MRI confirms stroke or TIA
- Blood pressure meets criteria for hypertensive emergency
- Symptoms progress or recur
- Patient cannot safely ambulate or has high fall risk
Discharge with close outpatient follow-up if:
- MRI negative for stroke
- Blood pressure controlled without target-organ damage
- Symptoms resolve with repositioning maneuver
- Patient can safely ambulate
Arrange follow-up within 2-4 weeks to:
- Reassess blood pressure control (target <130/80 mmHg for patients with CKD and diabetes) 2
- Monitor renal function and electrolytes 2
- Screen for secondary hypertension if malignant hypertension was present (20-40% have identifiable causes) 3
8. Patient Education and Safety
Counsel patient regarding:
- Medication adherence, as non-adherence is the most common trigger for hypertensive emergencies 3
- Home blood pressure monitoring with target <130/80 mmHg 2
- Return precautions: severe headache with vomiting, altered mental status, visual loss, chest pain, severe dyspnea, focal neurologic deficits, or seizures 3
- Fall risk and home safety assessment, particularly given CKD and multiple medications 1
- Avoid driving during acute episodes 4
Critical Pitfalls to Avoid
Do not assume a normal neurological examination excludes stroke – up to 80% of patients with stroke-related acute vestibular syndrome may have no associated focal neurologic deficits 1.
Do not rely solely on CT imaging – it frequently misses posterior circulation strokes 1.
Do not rapidly lower blood pressure in the absence of confirmed target-organ damage – this may cause cerebral, renal, or coronary ischemia in chronic hypertensives 3.
Do not dismiss "normal" blood pressure on presentation – patients with hypertensive emergencies may have fluctuating BP, and the history of transient weakness suggests prior severe elevations 3.
Do not use immediate-release nifedipine – it can cause unpredictable precipitous drops and increase stroke risk 3.