Interesting case I wanted to share with everyone

[otacon88]

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So I'm about 5 hours into my 12 hour shift when I see a new patient pop up on my track board - 31 year old with dizziness and nausea. I check his vitals, which are normal, and enter his room.
He says he woke up with really bad dizziness that started around 8am, had about 10 episode of n/v. Was completely fine the night before. I asked him about 10 times whether he was feeling dizzy as in light headed or dizzy as in vertigo type symptoms, he confirmed everytime it was light headedness and he felt like passing out, said he was only nauseous when talking and did not see the room spinning around him. Also adds on he feels really weak on the right side. Never happened before, hasn't been sick recently, no PMH, no medications, no drug use. This guy is built like an ox, healthier than probably even me.

I start my physical exam. Initially unremarkable. Neuro intact, strength 5/5 upper and lower extremities, grip strength 5/5 both hands, sensation intact all around. Get him up to stand, romberg negative, he's able to walk.

I'm thinking it's just another BPPV. Until I decide to just check his coordination. Finger to nose intact on the left side. Finger to nose grossly abnormal on the right - he was so ataxic he couldn't even touch my finger, kept hitting my wrist. At this point, I'm thinking ****, he's stroking out.

I opt to go straight for the MRI, but my attending wanted to get the CT first. Fine.
CT came back negative.
At this point I gave him fluids, meclizine, valium, zofran, none of which touched his symptoms.
Order the MR immediately. Take a look at the images myself and he's infarcted 3/4 of his right cerebellar hemisphere. Confirm it with the adc and dwi and it's an infarct. I honestly thought it would have been a cerebellar hemorrhage since he was so young.
Had the neurologist seeing him before the Radiologist even called me to confirm the read.

After seeing this case, I know I'm going to be much more liberal in looking for posterior strokes in patients with dizziness. And although n=1, light headedness can still be a sign for posterior stroke, as opposed to only vertigo. I'm glad I had the insight to test his coordination out early, otherwise we would have prolonged getting that MR.

 

[name?]

Any risk factors for dissection? Scary business.

 

[Arcan57]

I understand the impulse, but hunting posterior circulation stroke in a patient with lightheadedness and no other symptoms with nl neuro exam is a fool's errand. You had a guy with persistent vomiting and ataxia which is pretty classic for a posterior event. It's interesting (and scary) that he was so young but strokes do happen in all ages. Your take home should be to do a good neuro exam on patients with dizziness.

 

[dotcb]

Agree - the case to worry about is the one with benign exam and scary pathology. No one would miss this case with those findings on exam. Ambulating the patient and doing finger to nose are extremely high yield in assessing the dizzy patient.

 

[WilcoWorld]

Good pick up, but this sounds more like a case for doing a thorough neuro exam (and focusing on the cerebellum/spine) in patients with dizziness than for ordering MR scans. But maybe that's what you meant.

Personally, I put a lot more stock in my neuro exam than I do in a patient's description of dizziness. It's just not something that people are good at describing. My dad is very articulate AND is a physician, but when he was sick, he couldn't describe his dizziness worth a damn.

 

[Birdstrike]

So I'm about 5 hours into my 12 hour shift when I see a new patient pop up on my track board - 31 year old with dizziness and nausea. I check his vitals, which are normal, and enter his room.
He says he woke up with really bad dizziness that started around 8am, had about 10 episode of n/v. Was completely fine the night before. I asked him about 10 times whether he was feeling dizzy as in light headed or dizzy as in vertigo type symptoms, he confirmed everytime it was light headedness and he felt like passing out, said he was only nauseous when talking and did not see the room spinning around him. Also adds on he feels really weak on the right side. Never happened before, hasn't been sick recently, no PMH, no medications, no drug use. This guy is built like an ox, healthier than probably even me.

I start my physical exam. Initially unremarkable. Neuro intact, strength 5/5 upper and lower extremities, grip strength 5/5 both hands, sensation intact all around. Get him up to stand, romberg negative, he's able to walk.

I'm thinking it's just another BPPV. Until I decide to just check his coordination. Finger to nose intact on the left side. Finger to nose grossly abnormal on the right - he was so ataxic he couldn't even touch my finger, kept hitting my wrist. At this point, I'm thinking ****, he's stroking out.

I opt to go straight for the MRI, but my attending wanted to get the CT first. Fine.
CT came back negative.
At this point I gave him fluids, meclizine, valium, zofran, none of which touched his symptoms.
Order the MR immediately. Take a look at the images myself and he's infarcted 3/4 of his right cerebellar hemisphere. Confirm it with the adc and dwi and it's an infarct. I honestly thought it would have been a cerebellar hemorrhage since he was so young.
Had the neurologist seeing him before the Radiologist even called me to confirm the read.

After seeing this case, I know I'm going to be much more liberal in looking for posterior strokes in patients with dizziness. And although n=1, light headedness can still be a sign for posterior stroke, as opposed to only vertigo. I'm glad I had the insight to test his coordination out early, otherwise we would have prolonged getting that MR.

In my experience it's the gait testing that has nailed the CVA diagnosis when trying to differentiate between central and peripheral vertigo. Obviously in the young, like this patient, you are going to be heavily biased towards peripheral, benign vertigo. I'm surprised this guy had an abnormal finger to nose test, but could walk okay. But, good job, your exam nailed it. Cases like this are easy to miss. I've picked up more than one central vertigo on gait testing alone.

Also, the profuse nausea and vomiting surprises me. For some reason, in my experience (maybe just anecdotal) the strokes tend to be super dizzy but without nearly as much nausea and vomiting, whereas the peripheral vertigos tend to vomit more, and be paradoxically much more visibly uncomfortable. I agree with Wilcoworld, that your case argues more for a good neuro exam in vertigo patients, not so much for getting an MRI. You're not going to get an MR on every vertigo, and the only thing that triggered you to order it, was the fact that you found a neuro deficit on exam and didn't talk yourself out of it due to the patient's (falsely) reassuring age. Always have a "benign" vertigo patient prove they can walk and do finger to nose adequately before sending them home.

Also, someone brought up a good point regarding internal carotid artery dissection. That's a very good thought, although in the few I've seen, there's alway been some sort of weird head, neck or facial pain along with the neuro symptom that doesn't initially seem to make sense until you start thinking ICA dissection (pain + neuro deficit = vascular). Those are incredibly easy to miss, also.

Good work Otacon88.

 

[otacon88]

Good pick up, but this sounds more like a case for doing a thorough neuro exam (and focusing on the cerebellum/spine) in patients with dizziness than for ordering MR scans. But maybe that's what you meant.

Personally, I put a lot more stock in my neuro exam than I do in a patient's description of dizziness. It's just not something that people are good at describing. My dad is very articulate AND is a physician, but when he was sick, he couldn't describe his dizziness worth a damn.

Ah yes I meant doing a thorough neuro exam and not just getting an MR on every dizzy patient. I made that post after a long overnight and I was sleep deprived! haha

And thank you Birdstrike! I was pretty impressed with myeslf honestly, I'd say one of the first cases that was more severe than just run of the mill appy or chole that I found on history and physical alone before getting any labs or imaging. But then again I am only an intern and have much time ahead of me!

 

[diphenyl]

Excellent pick up. This is a definite case that will be in the back of my mind making my booty pucker next time we see the usual BS dizzy guy. Think is was an aneurism that clotted?

 

[UnderwaterDoc]

That's great that you have MRI so quickly available, where I'm at it would have been a nightmare because we very rarely can get MRI's from the ED. Cases like this get CTAs of the head/neck and get admitted to neuro for MRI. I would love love love to have MRI available to us.

Great case.

 

[ptarmigan]

Good neuro exam. I would have ordered hte CTH as well. So did did the image neck vessels? I would think a dissection that would be just as likely, if not more likely than CVA, in a 31 year old.