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Real Doctors (Life Makers)  |  Clinical  |  Medicine & medical subspecialities  |  A 58-year-old man with severe dizziness and vomiting « previous next »
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cleo_md
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A 58-year-old man with severe dizziness and vomiting
« on: /October/ 30, 2005, 04:24:04 PM »

A 58-year-old man was brought to the emergency department because of severe dizziness and vomiting. The symptoms began abruptly after breakfast, several hours before admission. He had been in good general health and had not seen a physician in "years." After noting the initial blood pressure, the patient recalled that he had once been told he had "white-coat" hypertension.

On examination, the vertigo was so severe that the patient could not sit upright, and it was difficult to determine whether ataxia was present. He had nausea and frequent emesis. The initial vital signs included a pulse of 115 beats/min, blood pressure of 215/114 mm Hg, and a temperature of 37.1?C. Abnormal physical findings included nystagmus when he looked to the right, hoarseness, and deviation of the uvula to the left. Perception of touch was intact on the face and extremities, but he had loss of temperature and pinprick sensations on the right side of his face and on his left side, including the trunk and extremities. He did not appear to have any motor weakness, and his speech content and orientation were appropriate. He had no hearing loss, no facial paralysis, and his pupils were equal and reactive


1-What are some medical problems that can present with vertigo?

2-The abnormal neurologic examination results suggest an infarction. Which areas of the brain appear to be affected?

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dr_b.e.s.m
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Re: A 58-year-old man with severe dizziness and vomiting
« Reply #1 on: /November/ 06, 2005, 08:51:53 AM »

It looks like Lateral medullary syndrome (Wallenburg) due to occlusion of posterior inferior cerebellar artery.

Area affected is the cerebellum and lateral part of medulla oblongata ( on the right side in this case ) .
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dr_b.e.s.m
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Re: A 58-year-old man with severe dizziness and vomiting
« Reply #2 on: /November/ 07, 2005, 07:29:35 AM »

In lat. medullary syndrome , there are:

-Vomiting & vertigo
-Contralat. pain and temp. loss in trunk and extremities. (left side in this case)
-Ipsilat. pain and temp. loss in face. (rt. side in this case)
-Ipsilat. paralysis of palate and larynx (here seen as hoarsness and deviation of the uvula , uvula is deviated towards the healthy side)
-Ipsilat. hemiataxia (seen here as nystagmus , towards side of the lesion)
-Horner syndrome , but here pupils are equal !!!

The only point against diagnosis is absence of Horner syndrome
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cleo_md
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Re: A 58-year-old man with severe dizziness and vomiting
« Reply #3 on: /November/ 07, 2005, 03:50:22 PM »

Dr B.E.S.M , I bow to your in respect!! I am honeslty impressed . Mashaa'Allah Aleik .
You are absolutely correct



The signs and symptoms described are consistent with a lesion in the inferior cerebellum and local structures. The posterior inferior cerebellar artery (PICA) supplies this region, which includes the lateral medulla, the inferior cerebellar peduncle, and the inferior cerebellum. The medial branch of the artery supplies the vermis and vestibulocerebellum, and these also may be involved.

Some variability in the anatomy of the vascular supply of the PICA exists, so a variety of symptoms may develop, depending on the territory affected.

The acute onset of severe vertigo is consistent with ischemic involvement of the inferior vestibular nucleus. Vomiting is a result of vestibulosympathetic and vestibulovagal stimulation.

Ipsilateral paralysis of the palate, larynx, and pharynx can result from involvement of the nucleus ambiguus or the 10th nerve as it crosses the medulla. Clinically, the patient has dysarthria, dysphonia, and dysphagia.

Involvement of the spinal tract of the fifth cranial nerve can result in facial paresthesias and ipsilateral loss of pain and temperature sensations on the face. Pain and temperature sensations are also lost on the contralateral side (limbs and trunk) because of involvement of the lateral spinothalamic tract.

A partial Horner syndrome may develop, with miosis and ptosis on the ipsilateral side of the face due to involvement of the descending sympathetic fibers in the medullary reticular formation. If the entire sympathoexcitatory pathway (along the lateral brain stem) is affected, there will also be a loss of sweating on the ipsilateral half of the body (central Horner syndrome).

Nystagmus is present, with a maximum response when the patient is looking toward the side that the infarction is on, due to the effects on the inferior cerebellar peduncle or on the inferior cerebellum. Gaze palsies may also develop with involvement of the lateral cerebellum.

Occasionally, the infarction will spread beyond the lateral medullary area and cause mild ipsilateral facial weakness and mild contralateral hemiparesis.

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cleo_md
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Re: A 58-year-old man with severe dizziness and vomiting
« Reply #4 on: /November/ 07, 2005, 03:51:12 PM »

As for question 1

1-What are some medical problems that can present with vertigo?


Numerous medical problems can present with varying degrees of vertigo. Otitis media and sometimes otitis externa can cause mild vertigo and are usually accompanied by acute onset of ear pain. Acute labyrinthitis and mastoiditis can present with more significant vertigo. Diseases of the acoustic nerve, such as vestibular neuronitis, Ramsay Hunt syndrome, Meniere's disease, acoustic neuroma, and meningioma can present with vertigo and varying degrees of hearing loss. Ototoxic drugs, such as aminoglycosides and loop diuretics, can cause vertigo as well as hearing loss. Benign positional vertigo may also occur; this is the most common cause of vertigo, but it is usually not severe and is characterized by brief episodes of vertigo that occur with position changes.

Central nervous system conditions that can cause vertigo include multiple sclerosis, post-traumatic vertigo, central nervous system infection, basilar migraine, tumors, vertebrobasilar insufficiency, and vascular infarction or hemorrhage.

A patient may report dizziness and will need to be asked to clarify whether the dizziness is a sensation of spinning (vertigo) or a light-headed sensation (eg, positional hypotension). Positional hypotension may be caused by a variety of medical problems, including severe anemia, dehydration, blood loss, advanced peripheral vascular disease, antihypertensive therapy and other drugs, and peripheral neuropathy. A vague light-headed feeling may follow a concussion or may occur during a viral illness.

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cleo_md
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Re: A 58-year-old man with severe dizziness and vomiting
« Reply #5 on: /November/ 07, 2005, 03:52:26 PM »

What are the immediate and long-term sequelae of this type of infarction?

Although many of the deficits are permanent, some recovery may occur. The nystagmus may continue, but the acute vertigo and its associated nausea and vomiting resolve. Most patients have residual laryngeal and pharyngeal weakness (including vocal cord paresis or paralysis) and impaired sensation on the extremities. In addition, any hemiparesis or disruption of sympathetic supply (Horner syndrome) may persist.

Very large infarctions may result in confusion or even coma as a result of compression on the brain stem. Hydrocephalus, hematoma, and herniation of the brain stem can also develop because of swelling, bleeding, and compression. Emergent surgical decompression may be required for these complications.


How can stroke syndrome that results from a PICA deficit be distinguished from strokes in other areas of the cerebellum?

The vascular supply to the cerebellum can be variable, so the clinical findings of strokes in this area may differ. Nevertheless, the following general descriptions may help distinguish the PICA stroke syndrome from other types of cerebellar strokes. Ultimately, imaging will be needed to determine the anatomy and distribution of the vascular supply, which may allow a better understanding of a given patient's clinical presentation.

A stroke that affects the distribution of the anterior inferior cerebellar artery (AICA) is characterized by vertigo, nausea, vomiting, and nystagmus, just as is a stroke in the PICA distribution area. However, in addition, ipsilateral deafness and facial paralysis exist because of ischemia to the lateral pontomedullary tegmentum.

A stroke affecting the superior cerebellar artery also may result in vertigo, but this type of stroke is less common. Nystagmus, Horner syndrome, and ataxia develop. Additionally, hearing loss occurs because of involvement of the lateral lemniscus; a contralateral 4th nerve palsy also may be present.

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cleo_md
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Re: A 58-year-old man with severe dizziness and vomiting
« Reply #6 on: /November/ 07, 2005, 03:54:10 PM »


What immediate treatments are appropriate?

Magnetic resonance imaging is the diagnostic test of choice, as it can detect ischemic strokes in the brain stem and cerebellum earlier than computed tomography can. Vascular imaging and evaluation of perfusion with single photon emission computed tomography and positron emission tomography may be useful in determining whether treatable vascular lesions, such as aneurysm or ateriovenous malformation, were responsible for the ischemia.

The treatment for stroke depends on the type of stroke. Treatment with tissue plasminogen activator (t-PA) has been shown to reduce the neurologic deficits from ischemic strokes that are not associated with bleeding (as identified on magnetic resonance imaging or computed tomography) in a patient who is evaluated within 3 hours of onset of symptoms. Exclusion criteria for treatment with t-PA are multiple and are aimed at minimizing the risk for bleeding due to treatment.

Evaluation for other treatable causes of stroke (eg, cardiac embolic source, vascular malformation) should begin once the patient is stable.

This particular patient was not an appropriate candidate for t-PA because he presented too late in the course of his symptoms, and his blood pressure was too high. The blood pressure rises acutely in most stroke patients and then gradually returns to normal. The decision to treat hypertension in an acute stroke must be made individually for each patient. In this case, the decision was made to treat the elevated blood pressure, with the goal of gradually reducing the pressure over a period of 2 to 3 days.


What risk factors need to be addressed in this patient's long-term care?
The known risk factors for stroke include nonmodifiable factors and modifiable factors. The nonmodifiable risk factors are aging, ethnicity, and inherited genetic factors. Of greater interest are the factors that can be modified, and these include hypertension, pre-existing cardiovascular disease, diabetes, smoking, hyperlipidemia, sedentary lifestyle, and carotid stenosis.

It is important to note that the most significant modifiable risk factor for stroke is hypertension. The risk of stroke can be decreased by 35% to 40% by decreasing systolic blood pressure by 10 mm Hg. Even greater benefits can be found in diabetic patients who are treated aggressively to control hypertension.

In this patient, it would be important to evaluate his risk factors once he is stable. Hyperlipidemia, persistent hypertension, diabetes, and other modifiable conditions should be treated. In addition, he should be followed up carefully to determine whether he has chronic hypertension. If so, the hypertension should be treated with a goal of maintaining a normal blood pressure.

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Fernando
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Re: A 58-year-old man with severe dizziness and vomiting
« Reply #7 on: /September/ 05, 2007, 08:53:04 AM »

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