Almost missed a cerebellar infarct v. vertigo

[keeping-it-real]

Early 60's guy with no PMH, non-smoker comes in with family and complains of dizziness with marked nausea and vomiting since yesterday morning. Denies headache, neck pain, etc... his only complaints are the imbalance, dizziness and the vomiting and they are all reproduced and worsened with change in head position. On exam, has a normal neuro exam with no cerebellar signs and has a positive dix-hallpike with horizontal nystagmus induced. Non-contrast CT head is negative (per wife, he may have hit his head yesterday). I tried the epley maneuver twice without resolution of symptoms. He got meclizine and zofran and was much better post meds. Upon further questioning it was discovered he had a year long history of tinnitus.

So i'm thinking either BPPV or Meniere's and discuss this with the family and talk about follow up care. They mention they're not completely comfortable and then someone in the family brings up that he's had double vision with this. I rexamined him and his visual fields had no evidence of deficit, no rotary or vertical nystagmus, etc...all normal.

After thinking about it for too long, I finally decided to get an MRI/MRA of the head...and sure enough he had a large left cerebellar infarct. It was humbling to say the least. Definitely a near miss on my part but I guess the diplopia was enough to make me feel something wasn't right.

Anyway, I thought it was an interesting case that really highlights the difficulty in distinguishing peripheral vs central vertigo.

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[EM_Rebuilder]

Great pickup...

My question is how big of a deal would a miss have been? If the person had appropiate followup and further outpatient workup; which would have assumably included an MRI espically when symptoms did not resolve.

I know we are seeing more and more MRI use done while in the ED, but even at big centers, MRI is often not 24/7 and in small shops is unaccessible without a transfer to another facility...

Thoughts?

 

[mauricekenter]

Did you walk the guy? I am wondering how his balance/gait was because I've heard it is a very distinguishing factor between stroke vs the rest.

 

[keeping-it-real]

Great pickup...

My question is how big of a deal would a miss have been? If the person had appropiate followup and further outpatient workup; which would have assumably included an MRI espically when symptoms did not resolve.

I know we are seeing more and more MRI use done while in the ED, but even at big centers, MRI is often not 24/7 and in small shops is unaccessible without a transfer to another facility...

Thoughts?

I don't know what the natural progression would've been but I think worst case includes the possibility of posterior fossa swelling with herniation.

Also, speaking of MRI, I'm at a fairly small shop with single coverage and it just happened that the tech was there and willing to do the study. As the saying goes, it's better to be lucky...

 

[keeping-it-real]

Did you walk the guy? I am wondering how his balance/gait was because I've heard it is a very distinguishing factor between stroke vs the rest.

You know, I didn't. He had no truncal ataxia in the bed, but given his c/o imbalance, I should've gotten him up and tested his gait.

 

[EM_Rebuilder]

I don't know what the natural progression would've been but I think worst case includes the possibility of posterior fossa swelling with herniation.

Also, speaking of MRI, I'm at a fairly small shop with single coverage and it just happened that the tech was there and willing to do the study. As the saying goes, it's better to be lucky...

Yeah, espically anything of size that certainly becomes a concern. I figure there would be some possibility of hemorrhagic transformation. Cases like this are what should keep us all worried and on our feet about how easy it is to miss something...

I wonder at what point we will see MRI use really become a SOC in many ED settings... I am certain it will happen; someone had this same conversation 10-20 years ago about CTs....

 

[tkim]

I wonder at what point we will see MRI use really become a SOC in many ED settings... I am certain it will happen; someone had this same conversation 10-20 years ago about CTs....

That will be a battle between radiology and the ER. Few techs want to be on call nights and weekends, much less do set shifts.

 

[Rendar5]

did you do head impulse testing or skew deviation? 2 newer neurologic physical exam signs to differentiate the two since central and periphera both cause nystagmus, positional vertigo, etc.

good pick-up on the case just not acting right.

 

[EMFreakz]

interesting. I had a very similiar case in the past month. cerebellar infarct. Totally normal neuro exam including gait and finger to nose etc. Thankfully, my gut told me to get a CT scan. Neurology's notes also documented a normal neuro exam. Guy ended up progressing to hydrocephalus and shipped out to academic center the next day to neuro ICU. so yes, it would be a big deal to miss it. I did have a milder case several years back. definitely keeps us on our toes.

 

[TysonCook]

I've had both and sent one home to return (no bad outcome, just not getting better). I've also had a personal friend get sent home with one, and his wife called me saying that he couldn't walk, kept falling to the right and was having worsening headache. I told her to take him back the next AM, and he had one as well found on MRI.

At one place I work the SOC is the MRI if you have any questions, the other is still CT with admit for MRI (as MRI is only available M-F 9-5)....

It is brought up again and again from our M+M all the way to the crapper rags, be cautious with "vertigo"... 🙂

 

[docB]

Does relief with Antivert in the ED play into anyone's decision process?

 

[Interpolfanclub]

Does relief with Antivert in the ED play into anyone's decision process?

Yes. If someone has a classic presentation for BPPV, has pos DH and gets better with meds and can walk out the door those are the ones that get sent home. If anyone doesn't fit that description I've typically gotten MRIs even if I have to call in the tech from home to do it at night. A patient with anything the least bit concerning gets an MRI. No relief after meds and still really dizzy when you walk? MRI. Elderly and poor historian with an MI and DM? MRI. You get the idea.

Part of my caution comes from my experience. I neglected to get a HCT on an elderly man who felt "weak and dizzy" with some vomiting but had no truncal ataxia and normal finger to nose. Anyone guess the DX? Large cerebellar bleed found by the hospitalist who did get a CT.

No I did not walk the patient due to his frailty. Does that mean we should get HCTs on old frail people who are too weak to walk and feel "dizzy?" I still haven't figured that out yet. I wish everyone read the textbook and came in the way that they are supposed to, but they keep trying to trick me.

 

[leviathan]

This is a really good link for differentiating stroke from benign causes of vertigo.

http://emcrit.org/podcasts/posterior-stroke/

 

[Indryd]

This is a really good link for differentiating stroke from benign causes of vertigo.

http://emcrit.org/podcasts/posterior-stroke/

This you guys.

Newman-Toker is a stud. This is for real and saves neurologists who are facile with it a lot of time and their hospitals a lot of money.

They look like badasses sending home patients who everyone else is in a panic about.

I've seen local neurologists walk into an ED bay, do their normal H and P, then do the HINTS exam and walk away satisfied when EPs were ready to transfer for emergent MRI.

 

[WilcoWorld]

HiNTS is a potentially useful physical exam constellation in the right hands, but it's worth noting that the examiners in the cited article were vertigo-specializing neurologists and I don't think inter-rater reliability was reported. Head Impulse testing isn't as easy as it sounds. Before you start discharging patients that you're worried about based on this it'd be nice to see how well this functions in non-neurologists' hands.

 

[deleted65604]

This you guys.

Newman-Toker is a stud. This is for real and saves neurologists who are facile with it a lot of time and their hospitals a lot of money.

They look like badasses sending home patients who everyone else is in a panic about.

I've seen local neurologists walk into an ED bay, do their normal H and P, then do the HINTS exam and walk away satisfied when EPs were ready to transfer for emergent MRI.

I've seen a 30 year old guy with no residual neuro deficits after a significant cerebellar stroke. Just because somebody has a good outcome doesn't mean you got the right diagnosis. A neurologist would save more time by not coming into the ER to examine somebody and just telling the ER doc to transfer them. A hospital would make more money by billing for an MRI, than not getting one. Hospitals make money by maximizing utilization of their services, not by minimizing them.

I'm not saying that a neurologist is wrong in their disposition of the patient you saw. I envy the asset of having a neurologist on hand to examine a patient in the ER. Most won't come in and do a history and physical as they are stuck in their clinic all day, after furiously rounding on their in-patients that morning. I will say that I have NEVER seen a neurologist in an ER in the past 3+ years. I read the links to the above articles and it seems like a sensitivity for a test of 50% is pretty stinking bad. Would it be fair to say that you might as well flip a coin?

 

[Hamhock]

HiNTS is a potentially useful physical exam constellation in the right hands, but it's worth noting that the examiners in the cited article were vertigo-specializing neurologists and I don't think inter-rater reliability was reported. Head Impulse testing isn't as easy as it sounds. Before you start discharging patients that you're worried about based on this it'd be nice to see how well this functions in non-neurologists' hands.

I completely agree with Wilco.

Indeed, "it'd be nice ot see how well this functions in non-neurologists' hands."

I know it doesn't work well in my hands/mind...and I think my exam skills are only a bit worse than the average ED doc.

I am not impressed by this research and the results have no impact on my clinical practice; although I wish they did.

HH

 

[DocRun1]

I would love a nice, solid clinical decision making rule for vertigo and cerebellar stroke. Anyone ready to embark on that?

 

[danielmd06]

I echo WilcoWorld. Those maneuvers aren't as easy to do (for me...and I completed a residency in neurology) as they appear at first blush in an article. And it is arguable that emergency personnel should become proficient in these examination tactics as the whole point is to tease out what is a stroke (an emergent condition) from a non-emergent condition.

In one sentence, an easy, easy thing to do in any dizzy patient is to make them walk and observe them for dysequilibrium. If they have a problem, you should suspect a stroke. No neuroloigst can argue with that statement.

There are plenty of articles (in the AAN green journal, otolaryngology lit, and in the EM lit) about vertigo, dizziness, and ruling out stroke. While I cannot offer 100% guarantees or foolproof algorithmic steps (no one can in neurologic disease) gleaned from residency, I can anecdotally (and simply) offer pointers for those interested:

(1) Peripheral pathology usually makes people feel *sicker* and look scarier than central pathology.
(2) Posterior circulation strokes have a relatively higher percentage of false negative MRI's than other strokes.
(3) If the dizzy patient can't walk or has affected gait, it's a stroke until proven otherwise.
(4) If there is ANYTHING else neurologic (and new) in a dizzy patient suggestive of a stroke (diplopia, slurred speech, headache, numbness, weakness, etc) it's a stroke until proven otherwise.
(5) Isolated vertigo is almost never indicative of mainstem basilar disease (which would require an actual intervention).
(6) A sensory exam helps out loads in this area (posterior circulation...remember the Wallenberg syndrome?) So many people miss this because they never, ever do a sensory exam and then get sued for missing a stroke.

There actually are some articles from this forum from maybe 2-6 month's ago on this topic...I remember when this came up but couldn't find them on a quick, simple search.

 

[WilcoWorld]

I echo WilcoWorld. Those maneuvers aren't as easy to do (for me...and I completed a residency in neurology) as they appear at first blush in an article. And it is arguable that emergency personnel should become proficient in these examination tactics as the whole point is to tease out what is a stroke (an emergent condition) from a non-emergent condition.

In one sentence, an easy, easy thing to do in any dizzy patient is to make them walk and observe them for dysequilibrium. If they have a problem, you should suspect a stroke. No neuroloigst can argue with that statement.

There are plenty of articles (in the AAN green journal, otolaryngology lit, and in the EM lit) about vertigo, dizziness, and ruling out stroke. While I cannot offer 100% guarantees or foolproof algorithmic steps (no one can in neurologic disease) gleaned from residency, I can anecdotally (and simply) offer pointers for those interested:

(1) Peripheral pathology usually makes people feel *sicker* and look scarier than central pathology.
(2) Posterior circulation strokes have a relatively higher percentage of false negative MRI's than other strokes.
(3) If the dizzy patient can't walk or has affected gait, it's a stroke until proven otherwise.
(4) If there is ANYTHING else neurologic (and new) in a dizzy patient suggestive of a stroke (diplopia, slurred speech, headache, numbness, weakness, etc) it's a stroke until proven otherwise.
(5) Isolated vertigo is almost never indicative of mainstem basilar disease (which would require an actual intervention).
(6) A sensory exam helps out loads in this area (posterior circulation...remember the Wallenberg syndrome?) So many people miss this because they never, ever do a sensory exam and then get sued for missing a stroke.

There actually are some articles from this forum from maybe 2-6 month's ago on this topic...I remember when this came up but couldn't find them on a quick, simple search.

These sound like great tips - do you mind giving a bit more detail as to which sensory findings we should specifically be looking for?

 

[TysonCook]

agreed....

The other problem that I run into is that the patients don't want to wait for an MRI (we can get them, but it is anywhere btw 2-6 hours from order to neurorad's read).

Its not that the patient isn't worried, they just don't want to wait.

I haven't had them sign an AMA form, but I do dictate that they are refusing to wait for an MRI and stroke is still on the DDX, along with having the family in the room and the RN/Resident.

This has happened to me twice in the last 3 months....

Anyone else run into this? Do you guys make them sign AMA?

 

[Apollyon]

Wallenberg's syndrome - the lateral medullary syndrome. One of the few things I recall off the cuff from neuro as a med student (because it was used as the example of why not to use an eponym).

 

[n2b8me]

😉

 

[Zanegray]

Recent article in Academic EM (this month I think) highlighted the importance of walking patients for questionable cord compression as well. I guess if they say they have weakness/dizziness walk 'em is a good rule.

 

[danielmd06]

These sound like great tips - do you mind giving a bit more detail as to which sensory findings we should specifically be looking for?

Thanks for the comments.

I would check the regular old extinction test on both sides (which 99% of people are doing for NIHSS anyway) in any stroke patient, and in these particular posterior stroke patients I would check proprioception of their toes/fingers, vibration, light touch, and pinprick. You can basically do the whole exam with no more equipment than a safety pin/broken stick/toothpick, and a free tuning fork from a drug rep. And they honestly don't take very long to do if you have the gear in your pocket.

Now, I'm not saying check every dermatome, but I'd go over these modalities if I was concerned about posterior circulation stroke. Remember to check their face, too! The deficits should be crossed.