- Email: [email protected]
Cerebellar stroke presenting with isolated dizziness: Brain MRI in 136 patients
Accepted Manuscript Cerebellar stroke presenting with isolated dizziness: Brain MRI in 136 patients
Michael D. Perloff, Nimesh S. Patel, Carlos S. Kase, Anuja U. Oza, Barbara Voetsch, Jose R. Romero PII: DOI: Reference:
S0735-6757(17)30484-9 doi: 10.1016/j.ajem.2017.06.034 YAJEM 56762
To appear in: Received date: Revised date: Accepted date:
12 April 2017 23 May 2017 21 June 2017
Please cite this article as: Michael D. Perloff, Nimesh S. Patel, Carlos S. Kase, Anuja U. Oza, Barbara Voetsch, Jose R. Romero , Cerebellar stroke presenting with isolated dizziness: Brain MRI in 136 patients, (2017), doi: 10.1016/j.ajem.2017.06.034
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Cerebellar stroke presenting with isolated dizziness: Brain MRI in 136 patients
Michael D. Perloff, MD, PhD* ([email protected])
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Nimesh S. Patel, MD+ ([email protected])
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Carlos S. Kase, MD* ([email protected])
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Anuja U. Oza, MD* ([email protected])
Barbara Voetsch# ([email protected])
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Jose R. Romero, MD* ([email protected])
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*From the Department of Neurology, Boston University School of Medicine, Boston University Medical Center, 72 E. Concord St, C3, Boston, MA 02118
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+From the Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390
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# Department of Neurology, Lahey Hospital & Medical Center, Burlington, MA Assistant Professor of Neurology, Tufts University School of Medicine
Address for correspondence: Michael D. Perloff, MD, PhD, Department of Neurology, Boston University School of Medicine 72 E. Concord St, C3, Boston, MA 02118 Phone: (617) 638-5343, Fax: (617) 638-5354, Email: [email protected]
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ACCEPTED MANUSCRIPT This study was done without funding of any type. Article type: Brief Report, word count: 1996 Key words: Isolated dizziness, dizzy, cerebellar stroke, MRI DWI
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Running head: Dizzy cerebellar stroke
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Author contributions: Study concept and design: Michael Perloff, Nimesh Patel, Carlos Kase, Barbara Voetsch, Jose R. Romero Acquisition of data: Michael Perloff, Nimesh Patel, Anuja Oza Analysis and interpretation of data: Michael Perloff, Nimesh Patel, Carlos Kase, Anuja Oza, Barbara Voetsch, Jose R. Romero Study supervision: Michael Perloff, Critical revision of manuscript for intellectual content: Michael Perloff, Nimesh Patel, Carlos Kase, Barbara Voetsch, Jose R. Romero,
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Disclosures: Michael Perloff has provided expert testimony for legal cases on neurologic pain and opioid toxicity.
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Carlos Kase has been on the Advisory Board at Boehringer-Ingelheim and had research support from Pfizer Astra-Zeneca Acorda Genentech and NIH.
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Nimesh Patel, Barbara Voetsch, Anuja Oza and Jose R. Romero have no disclosures.
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ACCEPTED MANUSCRIPT
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Cerebellar stroke presenting with isolated dizziness: Brain MRI in 136 patients
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Abstract:
Objective: To evaluate occurrence of cerebellar stroke in Emergency Department (ED)
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presentations of isolated dizziness (dizziness with a normal exam and negative neurological
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review of systems).
Methods: A 5-year retrospective study of ED patients presenting with a chief complaint of
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“dizziness or vertigo”, without other symptoms or signs in narrative history or on exam to
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suggest a central nervous system lesion, and work-up included a brain MRI with 48 hours.
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Patients with symptoms commonly peripheral in etiology (nystagmus, tinnitus, gait instability,
were recorded.
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etc) were included in the study. Patient demographics, stroke risk factors, and gait assessments
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Results: One hundred and thirty-six patients, who had a brain MRI for isolated dizziness, were included. There was a low correlation of gait assessment between ED physician and Neurologist (49 patients, Spearman’s correlation r2=0.17). Based on MRI DWI sequence, 3.7% (5/136 patients) had acute cerebellar strokes, limited to or including, the medial posterior inferior cerebellar artery vascular territory. In the 5 cerebellar stroke patients, mean age, body mass index (BMI), hemoglobin A1c, gender distribution, and prevalence of hypertension were similar 3
ACCEPTED MANUSCRIPT to the non-cerebellar stroke patient group. Mean LDL/HDL ratio was 3.63 ± 0.80 and smoking prevalence was 80% in the cerebellar stroke group compared to 2.43 ± 0.79 and 22%
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(respectively, p values< 0.01) in the non-cerebellar stroke group.
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Conclusions: Though there was preselection bias for stroke risk factors, our study suggests an
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important proportion of cerebellar stroke among ED patients with isolated dizziness, considering
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how common this complaint is.
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1.1 Introduction
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Dizziness is an ambiguous complaint, commonly seen in the Emergency Department (ED) and urgent care clinic. Millions of dizzy patients present each year, and represent about 4% of ED
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visits.[1] The term dizziness, as described by the patient, can refer to a broad range of
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complaints, including gait instability, lightheadedness-presyncope, vertigo or even consciousness clouding. The most frequent dizziness subtype is vertigo, which accounts for about 20-40% of
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the cases and typically involves dysfunction of the central or peripheral vestibular system.[1, 2] Although dizziness resolves or ceases to affect quality of life in about three-quarters of patients after three months,[3] it is critical that life-threatening or morbid diagnosis be ruled out during initial assessment. These diagnoses include stroke, ischemic heart disease, drug reaction, and acute infection among others. Stroke should certainly be suspected in a patient complaining of dizziness if they have concomitant risk factors and motor or sensory deficits. Clinicians do not 4
ACCEPTED MANUSCRIPT commonly consider cerebellar stroke in patients who complain of isolated dizziness (dizziness being the only symptom, with a normal exam and review of systems), although, cerebellar stroke signs and symptoms may be few. Approximately 11% of patients with cerebellar infarction present with isolated symptoms mimicking peripheral vestibular disorders.[4] However, what
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percentage of patients presenting with isolated dizziness harbor a cerebellar stroke, is unknown.
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diagnosis, knowledge of stroke etiology, or risk factor correction.
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As cerebellar stroke recovery can be rapid, patients may present and be discharged without
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Being able to distinguish peripheral causes of dizziness and stroke has important implications for the patient. Stroke is the fourth leading cause of death and the leading cause of
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long-term disability in the United States.[5] Dizziness is the leading symptom of posterior
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circulation strokes, particularly in those involving the cerebellum,[6] and often, it is the only symptom on presentation.[7] While cerebellar stroke itself does not typically lead to significant
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morbidity, it can be an initial warning sign for a more devastating brainstem stroke in the future.
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Previous studies researching the link between dizziness and stroke have shown different
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results based on the methods of diagnosing and detecting the disease.[4, 7-10] The populationbased study of in Kerber et al. showed that there was no increased risk of stroke in patients who
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presented with isolated dizziness. However, this study did not utilize MRI or uniform criteria to make the final diagnosis of stroke.[9] Many studies have suggested that the incidence of cerebellar stroke in patients presenting with isolated vertigo is higher than that diagnosed.[8, 11, 12] However, no study to date has looked at the incidence of cerebellar stroke in patients with isolated dizziness with diffusion weighted MRI as the gold standard.
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1.2 Material and methods
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1.2.1 Study Design
This was a 5-year retrospective review (01/01/2005-01/01/2010) of patients presenting to the ED
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with a chief complaint of “dizziness or vertigo” with no other symptoms or signs in narrative
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history or on exam to suggest a central nervous system lesion, and with work-up that included a brain MRI with 48 hours. ED physicians do not typically order brain MRI in the setting of
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obvious medical illness (infection, metabolic derangements, hypotension, hypertensive urgency,
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etc) and these patients were eliminated. Patients with nystagmus (lateralizing, unchanging), tinnitus, hearing loss, an abnormal head impulse test or Dix-Hallpike maneuver, or gait
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instability were included as these symptoms and signs are commonly peripheral in etiology.
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Two reviewers graded the ED physician and Neurology consult gait assessment and rated it as normal, widened/difficulty with stress gait, unsteady/ataxic but able to walk without assistance,
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or unable to walk with assistance. Any disagreements employed a third reviewer and a consensus rating was made (three occasions). Acute stroke was assessed by diffusion-weighted imaging on MRI. The study design was approved by the Boston Medical Center Institutional Review Board.
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ACCEPTED MANUSCRIPT The study was conducted at a 482-bed United States urban medical center.
1.2.3 Outcome Measures
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Patient demographics, past medical history, smoking habits, medications, and gait assessment by
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ED physician and Neurology consult were recorded. Lipid panel and hemoglobin A1C were also
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collected if done at the time of ED presentation or within one year prior. Parameter comparison
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of those with acute cerebellar stroke (based on MRI) to the general (non-cerebellar stroke)
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population were made.
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1.3 Statistics
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Non-cerebellar stroke patients and cerebellar stroke patients were compared for demographics
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and stroke risk factors using chi-squared for categorical variables and t-test numerical variable as appropriate. Analyses were conducted using two-sided tests and a significance level of 0.05. All
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statistical analyses were conducted using Social Science Statistics web based calculators
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(http://www.socscistatistics.com/tests/)
1.4 Results One hundred and seventy-four emergency department patients over 5 years with the chief complaint of dizziness or vertigo who were worked up with an acute brain MRI were evaluated. Thirty-eight patients with localized central neurological findings on chief complaint or on the 7
ACCEPTED MANUSCRIPT physical exam (assessed by ED physician or Neurology consult) were excluded from the study (Figure 1). These patients were excluded for cranial nerve palsy, dysarthria, aphasia, extremity weakness, and sensory deficit. Patients with abnormal gait findings were included in the study. Of the 136 ED patients who had a brain MRI for isolated dizziness, 103 (76%) had a Neurology
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consult placed. A gait exam was documented by the ED in 49% (66/136 patients) of cases and in
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87% (90/103 patients) of cases Neurology consult. Of these, 66% (44/66 patients) were recorded
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as having a normal gait exam by the ED, and 44% (40/90 patients) had normal exam documented by Neurology consult. There was a low correlation of gait assessment between ED and
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Neurology consult (49 patients, Spearman’s correlation r2=0.17).
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Based on MRI DWI sequence, 3.7% (5/136 patients) had acute cerebellar strokes, limited
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to or including, the medial posterior inferior cerebellar artery vascular territory (Figure 2A). Classic history of present illness (HPI) statements associated with cerebellar stroke were noted in
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all 5 patients and official radiology report confirms cerebellar stroke (Figure 2B). Gait exam was
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documented as normal for 2 of these cerebellar stroke patients and not documented for 3 of them per the ED evaluator. Gait was documented as abnormal for 3 cerebellar stroke patients (one
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unable to tandem, two ataxic but able to walk without assistance) and as normal in 2 of the
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patients per Neurology consult. In the 5 cerebellar stroke patients, mean age, body mass index (BMI), hemoglobin A1c, gender distribution, and prevalence of hypertension were similar to the non-cerebellar stroke patient group (Table 1). Mean LDL/HDL ratio mean was 3.63 ± 0.80 among the cerebellar stroke patients, while 2.43 ± 0.79 in the general population (p < 0.001). Active smoking or > 30 pack years was 80% (4/5 patients) in the cerebellar stroke patients and 22% (25/112 patients) in the general population (p < 0.01). None of the cerebellar stroke patients were taking aspirin daily, while 26% (35/136 patients) of the general population were 8
ACCEPTED MANUSCRIPT taking aspirin daily. Other anticoagulation or antiplatelet agents were rare, with no patients taking clopidogrel and only two general population patients taking warfarin. No cerebellar stroke patients reported a previous stroke or transient ischemic attack (TIA), while 12.5%
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1.5 Discussion
Common teaching suggests that in the absence of other signs and symptoms, cerebellar stroke is
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rare with dizziness as the lone presenting complaint. So-called “isolated dizziness” implies a
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chief complaint of dizziness, but with normal exam and neurological review of systems. In the present study, urgent MRI was performed in 136 patients with isolated dizziness and 5 cerebellar
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strokes were detected. With millions of isolated dizzy patients presenting to the ED each
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year,[1] a 3.7% rate of detection of cerebellar stroke is a very significant number. Of course, this
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is a biased study. ED attendings saw patients with isolated dizziness, but wanted a brain MRI none-the-less. They often consulted Neurology, but 25% of the time, an MRI was ordered
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without Neurology involvement. Why?, stroke risk factors. The cross-section population of 136 patients, where ED attendings wanted a brain MRI, are patients with stroke risk factors. This is
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obvious selection bias, and likely subtle features of each individual patient also affected ED attendings selection bias to order an MRI (and conversely, medically ill patients with obvious dizziness causes were excluded). However, this selection bias is not necessarily a negative study aspect. Cerebellar stroke would be less likely in an 18 year old normotensive non-smoker.
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ACCEPTED MANUSCRIPT Similar patient demographics and risk factors (Table 1) were seen in 53 patients with isolated dizziness and cerebellar stroke in the large (n=1613) cross-sectional study by Kerber et al.;[9] where cerebellar stroke patients were mean age 69.3 years, 72% hypertensive by medical history, and 23% smokers but had a higher frequency of previous CAD (40%) and TIA or stroke
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(28%) compared to our cohort (with 13.2% with CAD and 12.5% with previous TIA or stroke).
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Most importantly, in the Kerber et al. population, cerebellar stroke was only seen in 0.7% of
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patients with “isolated” dizziness; however, the diagnosis of cerebellar stroke was based on the neurologist’s final impression in the medical record, brain MRI not being ordered in most
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patients.[9] This suggests that our figure of 3.7% (of patients with documentation of cerebellar
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infarction in a cohort presenting to the ED with isolated dizziness) is more likely a reflection of
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reality, as the diagnosis was based on MRI findings in an acute setting of evaluation. Most patients in our study had a hypertensive history due to selection bias, but risk
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factors of obesity or elevated hemoglobin A1c were not more common in cerebellar stroke
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patients (Table 1). All of the cerebellar stroke patients had a LDL/HDL ratio approximately 1 standard deviation above the mean, or higher, (Table 1) and 4 of 5 were smokers. Furthermore,
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none of the cerebellar stroke patients were taking aspirin daily, though 26% of the general
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population was. This is striking, as it suggests that hyperlipidemia and smoking are important risk factors, and aspirin may be protective, for cerebellar stroke in isolated dizziness. However with only 5 cerebellar strokes, the subpopulation is a small sample. Neurology’s HPI did not parse out cerebellar strokes any more clearly than the ED’s history. However, noting of key aspects of the HPI can make cerebellar stroke more likely (Figure 2B). Difficulties with the patient’s report and assessing the etiology of dizziness have 10
ACCEPTED MANUSCRIPT been reported previously.[13] Abnormal gait was not considered an exclusion criterion in our study, as opinions differ on gait as a reliable indicator of potential cerebellar stroke versus a peripheral mechanism of dizziness.[8-10, 14] More specifically, gait assessment was done in 49% of patients evaluated by the ED physician, while Neurology consultants did 87%. In the
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patients where both the ED and Neurology did a gait exam, there was no correlation of their
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assessments (gait graded on a 4-point scale, see Methods), with a Spearman’s correlation of
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r2=0.17. In the 5 patients that had cerebellar strokes, Neurology consultants documented other exam findings (a negative head impulse test or subtle nystagmus findings for example) that made
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cerebellar stroke more likely,[10-12, 14] but these were not consistently applied to all patients
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seen by Neurology. Seminal cerebellar stroke studies about vestibular head impulse testing and nystagmus were introduced in 2008-2009 (when our study data were being collected),[11, 12]
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and these are now part of the standard Neurological exam when cerebellar stroke is questioned.
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All 5 cerebellar stroke patients had strokes including, or limited to, the medial posterior inferior cerebellar artery (PICA) territory. Stroke to this vascular territory have previously been
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associated with vertigo or dizziness in isolation.[14] Considering the above, with clinical
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presentation of isolated dizziness and significant stroke risk factors, acute brain MRI appears prudent. Though most patients will rapidly recover from small cerebellar strokes,[15]
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confirmation of a posterior circulation stroke changes workup and management, potentially preventing a future stroke event that could easily result in catastrophic brainstem infarct.
1.6 Conclusions:
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ACCEPTED MANUSCRIPT Isolated dizziness is a common presentation and patients with significant stroke factors (possibly focusing on hyperlipidemia and smoking habits) have a significant cerebellar stroke incidence. Gait assessment does not consistently stratify patients with greater stroke risk, so a low threshold
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for brain MRI seems reasonable even with a normal exam.
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1.7 Bibliography
[1] Cappello M, di Blasi U, di Piazza L, Ducato G, Ferrara A, Franco S, Fornaciari M, Sciortino
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A, Tarantino AM, di Blasi S, (1995) Dizziness and vertigo in a department of emergency
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medicine, Eur J Emerg Med. 2(4) 201-11.
[2] Kerber KA, Zahuranec DB, Brown DL, Meurer WJ, Burke JF, Smith MA, Lisabeth LD,
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Fendrick AM, McLaughlin T, Morgenstern LB, (2014) Stroke risk after nonstroke emergency
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department dizziness presentations: a population-based cohort study, Ann Neurol. 75(6) 899907.
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[3] Bailey KE, Sloane PD, Mitchell M, Preisser J, (1993) Which primary care patients with dizziness will develop persistent impairment?, Arch Fam Med. 2(8) 847-52. [4] Lee H, Sohn SI, Cho YW, Lee SR, Ahn BH, Park BR, Baloh RW, (2006) Cerebellar infarction presenting isolated vertigo: frequency and vascular topographical patterns, Neurology. 67(7) 1178-83.
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ACCEPTED MANUSCRIPT [5] Kochanek KD, Xu J, Murphy SL, Minino AM, Kung HC, (2011) Deaths: final data for 2009, Natl Vital Stat Rep. 60(3) 1-116. [6] Williams D, Wilson TG, (1962) The diagnosis of the major and minor syndromes of basilar insufficiency, Brain. 85 741-74.
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manifestation of vertebrobasilar ischemia, Neurology. 47(1) 94-7.
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[7] Gomez CR, Cruz-Flores S, Malkoff MD, Sauer CM, Burch CM, (1996) Isolated vertigo as a
or vascular disease?, Acta Neurol Scand. 91(1) 43-8.
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[8] Norrving B, Magnusson M, Holtas S, (1995) Isolated acute vertigo in the elderly; vestibular
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[9] Kerber KA, Brown DL, Lisabeth LD, Smith MA, Morgenstern LB, (2006) Stroke among
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patients with dizziness, vertigo, and imbalance in the emergency department: a population-based study, Stroke. 37(10) 2484-7. Epub 2006 Aug 31.
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[10] Huang CY, Yu YL, (1985) Small cerebellar strokes may mimic labyrinthine lesions, J
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Neurol Neurosurg Psychiatry. 48(3) 263-5.
[11] Newman-Toker DE, Kattah JC, Alvernia JE, Wang DZ, (2008) Normal head impulse test
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differentiates acute cerebellar strokes from vestibular neuritis, Neurology. 70(24 Pt 2) 2378-85.
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[12] Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE, (2009) HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination
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more sensitive than early MRI diffusion-weighted imaging, Stroke. 40(11) 3504-10. doi: 10.1161/STROKEAHA.109.551234. Epub 2009 Sep 17. [13] Newman-Toker DE, Cannon LM, Stofferahn ME, Rothman RE, Hsieh YH, Zee DS, (2007) Imprecision in patient reports of dizziness symptom quality: a cross-sectional study conducted in an acute care setting, Mayo Clin Proc. 82(11) 1329-40.
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ACCEPTED MANUSCRIPT [14] Kase CS, Norrving B, Levine SR, Babikian VL, Chodosh EH, Wolf PA, Welch KM, (1993) Cerebellar infarction. Clinical and anatomic observations in 66 cases, Stroke. 24(1) 76-83. [15] Kelly PJ, Stein J, Shafqat S, Eskey C, Doherty D, Chang Y, Kurina A, Furie KL, (2001) Functional recovery after rehabilitation for cerebellar stroke, Stroke. 32(2) 530-4.
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[16] Amarenco P, Hauw JJ, (1990) Cerebellar infarction in the territory of the anterior and
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inferior cerebellar artery. A clinicopathological study of 20 cases, Brain. 113(Pt 1) 139-55.
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[17] Kumral E, Kisabay A, Atac C, (2006) Lesion patterns and etiology of ischemia in the anterior inferior cerebellar artery territory involvement: a clinical - diffusion weighted - MRI
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study, Eur J Neurol. 13(4) 395-401.
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Figure Legend
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Figure 1: Study design for isolated dizziness population Figure 2: Brain MRI diffusion-weighted imaging of cerebellar stroke patients (A) with associated
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“history of present illness” and official radiology MRI report (B).
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ACCEPTED MANUSCRIPT Figure 1
Emergency room presentations
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01/01/2005 through 01/01/2010
Excluded (n=38): CNS localizing finding on history or exam by ED physician (not including gait)
Cranial nerve palsy: 10 patients Dysarthria/aphasia: 7 patients Extremity weakness: 10 patients Sensory deficit: 7 patients Extremity weakness and sensory deficit: 4 patients
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Included: Chief complaint of dizziness or vertigo and a brain MRI performed within 48 hours of presentation: 174 patients
Population: 136 patients with isolated dizziness and a brain MRI within 48 hours of presentation
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ACCEPTED MANUSCRIPT Table 1: Demographics and presentation assessment All Patients
Cerebellar strokes
patients 136
5/136 (3.7%)
Mean age (years)
59.8 ± 16.7 n=136
62.2 ± 12.0 n=5
Sex
80 women (59%)
3 women, 2 men
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Patients, n
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56 men (41%) 29.1 ± 5.6 (n=113)
LDL (mg/dL)
114.0 ± 37.1 (n=87)
HDL (mg/dL)
48.8 ± 12.8
LDL/HDL ratio
2.43 ± 0.79
Hemoglobin A1c (%)
6.6 ± 1.33 (n=66)
6.5 ± 1.51 (n=5)
Hypertension (by history or ED values)
104 patients (76%) n=131
4/5 patients (80%)
Coronary artery disease (by history)
18 patients (13.2%)
1/5 patients (20%)
Atrial fibrillation (by history)
4 patients (2.9%)
0/5 patients
Smokers (active or > 30 pack years)
25 patients (22%) n=112
4/5 patients (80%)*
Previous stroke or TIA
17 patients (12.5%) n=136
0/5 patients
35 patients (26%) n=136
0/5 patients
Taking clopidogrel
0 patients (0%) n=136
0/5 patients
Taking warfarin
2 patients (1.5%) n=136
0/5 patients
Gait assessment by ED
44 normal, 23 abnormal, 69 not documented
2 normal, 3 not documented
Gait assessment by Neurology consult
40 normal, 50 abnormal, 13 not documented
2 normal, 3 abnormal
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Taking aspirin
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Mean Body Mass Index
31.21 ± 4.8 (n=5) 153.2 ± 37.8 (n=5) 43.8 ± 13.4 3.63 ± 0.80**
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Body Mass Index, lipid panel, hemoglobin A1c were included if documented at presentation, or within 1 year prior. Smoking habits were included when documented at presentation. T-test was used for continuous variable, Chi-squared test was applied on categorical variables. *p value < 0.01, ** p value < 0.001
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Abbreviations: low density lipoprotein:high density lipoprotein ratio (HDL: LDL); transient ischemic attack (TIA); Emergency Department (ED)
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ACCEPTED MANUSCRIPT Figure 2B ED presentation quotation: Patient#1 “He has a history of vertigo but presents with an acute worsening vertigo episode. Described as the room moving- circles. Gets nauseated. Not particularly associated with motion, but has greatest sense when walking- feels very unsteady#. He also experience tinnitus in both ears% (this is new for him over past few days). The dizziness seem random to the patient, but walking is most difficult#.”
MRI report: There is an area of restricted diffusion on the posterior right cerebellum and also a smaller focus of restricted diffusion within the lateral aspect of the right cerebellum and the superior aspect of the left cerebellum. These findings are consistent with recent subacute infarcts. There is associated T2 and FLAIR signal hyperintensity with these lesions.
Patient#2 “4 days of constant lightheadedness, episodic dizziness feeling like the room is spinning$, nausea, brief episodes of sharp substernal chest pain. Her lightheadedness has persisted and is not related to positioning. She states that her legs gave out and she fell to the floor twice this weekend#. She states she felt a similar episode coming on today at work, but was able to brace herself against a wall and not fall.”
There are several foci of restricted diffusion consistent with recent infarcts in the bilateral cerebellar hemispheres. No other areas of restricted diffusion identified. There are 2 areas of FLAIR hyperintensities within the right cerebellum, which are stable since the prior MRI.
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Patient#3 “For the past week he has been having posterior neck pain which radiates to the back of his skull causing him moderate headache *….awoke, feeling "dizzy", room was spinning, he had to grab hold of walls to walk and felt very unbalanced.#,$ He normally uses a cane at baseline due to peripheral neuropathy, however claims his gait today is not his normal# ”
There is restricted diffusion in the left inferior medial cerebellum, with associated abnormal T2 and FLAIR signal, consistent with a recent infarct.
Patient#4 “She came in to the ED with a chief complaint of unsteadiness# and dizziness for several days. Now she is feeling much better, almost back to baseline. ”
Multiple foci of restricted diffusion with associated T2/FLAIR hyperintense signal are noted within the right cerebellar hemisphere more so in a posterior-inferior distribution consistent with a recent right PICA infarct. Multiple foci of small regions of susceptibility-related signal loss are seen within this infarct in the right
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ACCEPTED MANUSCRIPT cerebellar hemisphere consistent with blood products.
Patient#5 “Awoke at 3 am on Thanksgiving and felt that the whole room was spinning. She also noted a headache*, especially over the right side of the head/ear and increased ringing in her ear% (though she states that she has endured tinnitus in her ears for years).”
There are two small foci of restricted diffusion within the inferior medial aspect of the right cerebellar hemisphere consistent with acute infarct involving the vascular territory of the right PICA.
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# Gait complaints on a dizzy presentation make cerebellar stroke more likely; 4,14 a 4-fold higher risk9
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% Cerebellar strokes can present with tinnitus, especially with anterior inferior cerebellar artery (AICA) territory strokes
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* Headache is a common comorbid complaint with cerebellar strokes, present in approximately 50% of cases 14
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$ Nonspecific dizzy complaints (including lightheaded, vertigo, imbalance) are common 13
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Michael D. Perloff, Nimesh S. Patel, Carlos S. Kase, Anuja U. Oza, Barbara Voetsch, Jose R. Romero PII: DOI: Reference:
S0735-6757(17)30484-9 doi: 10.1016/j.ajem.2017.06.034 YAJEM 56762
To appear in: Received date: Revised date: Accepted date:
12 April 2017 23 May 2017 21 June 2017
Please cite this article as: Michael D. Perloff, Nimesh S. Patel, Carlos S. Kase, Anuja U. Oza, Barbara Voetsch, Jose R. Romero , Cerebellar stroke presenting with isolated dizziness: Brain MRI in 136 patients, (2017), doi: 10.1016/j.ajem.2017.06.034
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Cerebellar stroke presenting with isolated dizziness: Brain MRI in 136 patients
Michael D. Perloff, MD, PhD* ([email protected])
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Nimesh S. Patel, MD+ ([email protected])
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Carlos S. Kase, MD* ([email protected])
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Anuja U. Oza, MD* ([email protected])
Barbara Voetsch# ([email protected])
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Jose R. Romero, MD* ([email protected])
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*From the Department of Neurology, Boston University School of Medicine, Boston University Medical Center, 72 E. Concord St, C3, Boston, MA 02118
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+From the Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390
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# Department of Neurology, Lahey Hospital & Medical Center, Burlington, MA Assistant Professor of Neurology, Tufts University School of Medicine
Address for correspondence: Michael D. Perloff, MD, PhD, Department of Neurology, Boston University School of Medicine 72 E. Concord St, C3, Boston, MA 02118 Phone: (617) 638-5343, Fax: (617) 638-5354, Email: [email protected]
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ACCEPTED MANUSCRIPT This study was done without funding of any type. Article type: Brief Report, word count: 1996 Key words: Isolated dizziness, dizzy, cerebellar stroke, MRI DWI
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Running head: Dizzy cerebellar stroke
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Author contributions: Study concept and design: Michael Perloff, Nimesh Patel, Carlos Kase, Barbara Voetsch, Jose R. Romero Acquisition of data: Michael Perloff, Nimesh Patel, Anuja Oza Analysis and interpretation of data: Michael Perloff, Nimesh Patel, Carlos Kase, Anuja Oza, Barbara Voetsch, Jose R. Romero Study supervision: Michael Perloff, Critical revision of manuscript for intellectual content: Michael Perloff, Nimesh Patel, Carlos Kase, Barbara Voetsch, Jose R. Romero,
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Disclosures: Michael Perloff has provided expert testimony for legal cases on neurologic pain and opioid toxicity.
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Carlos Kase has been on the Advisory Board at Boehringer-Ingelheim and had research support from Pfizer Astra-Zeneca Acorda Genentech and NIH.
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Nimesh Patel, Barbara Voetsch, Anuja Oza and Jose R. Romero have no disclosures.
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Cerebellar stroke presenting with isolated dizziness: Brain MRI in 136 patients
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Abstract:
Objective: To evaluate occurrence of cerebellar stroke in Emergency Department (ED)
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presentations of isolated dizziness (dizziness with a normal exam and negative neurological
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review of systems).
Methods: A 5-year retrospective study of ED patients presenting with a chief complaint of
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“dizziness or vertigo”, without other symptoms or signs in narrative history or on exam to
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suggest a central nervous system lesion, and work-up included a brain MRI with 48 hours.
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Patients with symptoms commonly peripheral in etiology (nystagmus, tinnitus, gait instability,
were recorded.
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etc) were included in the study. Patient demographics, stroke risk factors, and gait assessments
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Results: One hundred and thirty-six patients, who had a brain MRI for isolated dizziness, were included. There was a low correlation of gait assessment between ED physician and Neurologist (49 patients, Spearman’s correlation r2=0.17). Based on MRI DWI sequence, 3.7% (5/136 patients) had acute cerebellar strokes, limited to or including, the medial posterior inferior cerebellar artery vascular territory. In the 5 cerebellar stroke patients, mean age, body mass index (BMI), hemoglobin A1c, gender distribution, and prevalence of hypertension were similar 3
ACCEPTED MANUSCRIPT to the non-cerebellar stroke patient group. Mean LDL/HDL ratio was 3.63 ± 0.80 and smoking prevalence was 80% in the cerebellar stroke group compared to 2.43 ± 0.79 and 22%
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(respectively, p values< 0.01) in the non-cerebellar stroke group.
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Conclusions: Though there was preselection bias for stroke risk factors, our study suggests an
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important proportion of cerebellar stroke among ED patients with isolated dizziness, considering
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how common this complaint is.
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1.1 Introduction
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Dizziness is an ambiguous complaint, commonly seen in the Emergency Department (ED) and urgent care clinic. Millions of dizzy patients present each year, and represent about 4% of ED
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visits.[1] The term dizziness, as described by the patient, can refer to a broad range of
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complaints, including gait instability, lightheadedness-presyncope, vertigo or even consciousness clouding. The most frequent dizziness subtype is vertigo, which accounts for about 20-40% of
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the cases and typically involves dysfunction of the central or peripheral vestibular system.[1, 2] Although dizziness resolves or ceases to affect quality of life in about three-quarters of patients after three months,[3] it is critical that life-threatening or morbid diagnosis be ruled out during initial assessment. These diagnoses include stroke, ischemic heart disease, drug reaction, and acute infection among others. Stroke should certainly be suspected in a patient complaining of dizziness if they have concomitant risk factors and motor or sensory deficits. Clinicians do not 4
ACCEPTED MANUSCRIPT commonly consider cerebellar stroke in patients who complain of isolated dizziness (dizziness being the only symptom, with a normal exam and review of systems), although, cerebellar stroke signs and symptoms may be few. Approximately 11% of patients with cerebellar infarction present with isolated symptoms mimicking peripheral vestibular disorders.[4] However, what
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percentage of patients presenting with isolated dizziness harbor a cerebellar stroke, is unknown.
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diagnosis, knowledge of stroke etiology, or risk factor correction.
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As cerebellar stroke recovery can be rapid, patients may present and be discharged without
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Being able to distinguish peripheral causes of dizziness and stroke has important implications for the patient. Stroke is the fourth leading cause of death and the leading cause of
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long-term disability in the United States.[5] Dizziness is the leading symptom of posterior
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circulation strokes, particularly in those involving the cerebellum,[6] and often, it is the only symptom on presentation.[7] While cerebellar stroke itself does not typically lead to significant
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morbidity, it can be an initial warning sign for a more devastating brainstem stroke in the future.
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Previous studies researching the link between dizziness and stroke have shown different
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results based on the methods of diagnosing and detecting the disease.[4, 7-10] The populationbased study of in Kerber et al. showed that there was no increased risk of stroke in patients who
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presented with isolated dizziness. However, this study did not utilize MRI or uniform criteria to make the final diagnosis of stroke.[9] Many studies have suggested that the incidence of cerebellar stroke in patients presenting with isolated vertigo is higher than that diagnosed.[8, 11, 12] However, no study to date has looked at the incidence of cerebellar stroke in patients with isolated dizziness with diffusion weighted MRI as the gold standard.
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1.2 Material and methods
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1.2.1 Study Design
This was a 5-year retrospective review (01/01/2005-01/01/2010) of patients presenting to the ED
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with a chief complaint of “dizziness or vertigo” with no other symptoms or signs in narrative
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history or on exam to suggest a central nervous system lesion, and with work-up that included a brain MRI with 48 hours. ED physicians do not typically order brain MRI in the setting of
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obvious medical illness (infection, metabolic derangements, hypotension, hypertensive urgency,
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etc) and these patients were eliminated. Patients with nystagmus (lateralizing, unchanging), tinnitus, hearing loss, an abnormal head impulse test or Dix-Hallpike maneuver, or gait
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instability were included as these symptoms and signs are commonly peripheral in etiology.
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Two reviewers graded the ED physician and Neurology consult gait assessment and rated it as normal, widened/difficulty with stress gait, unsteady/ataxic but able to walk without assistance,
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or unable to walk with assistance. Any disagreements employed a third reviewer and a consensus rating was made (three occasions). Acute stroke was assessed by diffusion-weighted imaging on MRI. The study design was approved by the Boston Medical Center Institutional Review Board.
1.2.2 Setting 6
ACCEPTED MANUSCRIPT The study was conducted at a 482-bed United States urban medical center.
1.2.3 Outcome Measures
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Patient demographics, past medical history, smoking habits, medications, and gait assessment by
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ED physician and Neurology consult were recorded. Lipid panel and hemoglobin A1C were also
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collected if done at the time of ED presentation or within one year prior. Parameter comparison
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of those with acute cerebellar stroke (based on MRI) to the general (non-cerebellar stroke)
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population were made.
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1.3 Statistics
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Non-cerebellar stroke patients and cerebellar stroke patients were compared for demographics
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and stroke risk factors using chi-squared for categorical variables and t-test numerical variable as appropriate. Analyses were conducted using two-sided tests and a significance level of 0.05. All
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statistical analyses were conducted using Social Science Statistics web based calculators
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(http://www.socscistatistics.com/tests/)
1.4 Results One hundred and seventy-four emergency department patients over 5 years with the chief complaint of dizziness or vertigo who were worked up with an acute brain MRI were evaluated. Thirty-eight patients with localized central neurological findings on chief complaint or on the 7
ACCEPTED MANUSCRIPT physical exam (assessed by ED physician or Neurology consult) were excluded from the study (Figure 1). These patients were excluded for cranial nerve palsy, dysarthria, aphasia, extremity weakness, and sensory deficit. Patients with abnormal gait findings were included in the study. Of the 136 ED patients who had a brain MRI for isolated dizziness, 103 (76%) had a Neurology
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consult placed. A gait exam was documented by the ED in 49% (66/136 patients) of cases and in
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87% (90/103 patients) of cases Neurology consult. Of these, 66% (44/66 patients) were recorded
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as having a normal gait exam by the ED, and 44% (40/90 patients) had normal exam documented by Neurology consult. There was a low correlation of gait assessment between ED and
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Neurology consult (49 patients, Spearman’s correlation r2=0.17).
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Based on MRI DWI sequence, 3.7% (5/136 patients) had acute cerebellar strokes, limited
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to or including, the medial posterior inferior cerebellar artery vascular territory (Figure 2A). Classic history of present illness (HPI) statements associated with cerebellar stroke were noted in
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all 5 patients and official radiology report confirms cerebellar stroke (Figure 2B). Gait exam was
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documented as normal for 2 of these cerebellar stroke patients and not documented for 3 of them per the ED evaluator. Gait was documented as abnormal for 3 cerebellar stroke patients (one
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unable to tandem, two ataxic but able to walk without assistance) and as normal in 2 of the
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patients per Neurology consult. In the 5 cerebellar stroke patients, mean age, body mass index (BMI), hemoglobin A1c, gender distribution, and prevalence of hypertension were similar to the non-cerebellar stroke patient group (Table 1). Mean LDL/HDL ratio mean was 3.63 ± 0.80 among the cerebellar stroke patients, while 2.43 ± 0.79 in the general population (p < 0.001). Active smoking or > 30 pack years was 80% (4/5 patients) in the cerebellar stroke patients and 22% (25/112 patients) in the general population (p < 0.01). None of the cerebellar stroke patients were taking aspirin daily, while 26% (35/136 patients) of the general population were 8
ACCEPTED MANUSCRIPT taking aspirin daily. Other anticoagulation or antiplatelet agents were rare, with no patients taking clopidogrel and only two general population patients taking warfarin. No cerebellar stroke patients reported a previous stroke or transient ischemic attack (TIA), while 12.5%
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(17/136 patients) of the general population reported previous stroke or TIA. (Table 1)
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1.5 Discussion
Common teaching suggests that in the absence of other signs and symptoms, cerebellar stroke is
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rare with dizziness as the lone presenting complaint. So-called “isolated dizziness” implies a
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chief complaint of dizziness, but with normal exam and neurological review of systems. In the present study, urgent MRI was performed in 136 patients with isolated dizziness and 5 cerebellar
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strokes were detected. With millions of isolated dizzy patients presenting to the ED each
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year,[1] a 3.7% rate of detection of cerebellar stroke is a very significant number. Of course, this
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is a biased study. ED attendings saw patients with isolated dizziness, but wanted a brain MRI none-the-less. They often consulted Neurology, but 25% of the time, an MRI was ordered
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without Neurology involvement. Why?, stroke risk factors. The cross-section population of 136 patients, where ED attendings wanted a brain MRI, are patients with stroke risk factors. This is
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obvious selection bias, and likely subtle features of each individual patient also affected ED attendings selection bias to order an MRI (and conversely, medically ill patients with obvious dizziness causes were excluded). However, this selection bias is not necessarily a negative study aspect. Cerebellar stroke would be less likely in an 18 year old normotensive non-smoker.
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ACCEPTED MANUSCRIPT Similar patient demographics and risk factors (Table 1) were seen in 53 patients with isolated dizziness and cerebellar stroke in the large (n=1613) cross-sectional study by Kerber et al.;[9] where cerebellar stroke patients were mean age 69.3 years, 72% hypertensive by medical history, and 23% smokers but had a higher frequency of previous CAD (40%) and TIA or stroke
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(28%) compared to our cohort (with 13.2% with CAD and 12.5% with previous TIA or stroke).
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Most importantly, in the Kerber et al. population, cerebellar stroke was only seen in 0.7% of
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patients with “isolated” dizziness; however, the diagnosis of cerebellar stroke was based on the neurologist’s final impression in the medical record, brain MRI not being ordered in most
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patients.[9] This suggests that our figure of 3.7% (of patients with documentation of cerebellar
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infarction in a cohort presenting to the ED with isolated dizziness) is more likely a reflection of
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reality, as the diagnosis was based on MRI findings in an acute setting of evaluation. Most patients in our study had a hypertensive history due to selection bias, but risk
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factors of obesity or elevated hemoglobin A1c were not more common in cerebellar stroke
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patients (Table 1). All of the cerebellar stroke patients had a LDL/HDL ratio approximately 1 standard deviation above the mean, or higher, (Table 1) and 4 of 5 were smokers. Furthermore,
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none of the cerebellar stroke patients were taking aspirin daily, though 26% of the general
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population was. This is striking, as it suggests that hyperlipidemia and smoking are important risk factors, and aspirin may be protective, for cerebellar stroke in isolated dizziness. However with only 5 cerebellar strokes, the subpopulation is a small sample. Neurology’s HPI did not parse out cerebellar strokes any more clearly than the ED’s history. However, noting of key aspects of the HPI can make cerebellar stroke more likely (Figure 2B). Difficulties with the patient’s report and assessing the etiology of dizziness have 10
ACCEPTED MANUSCRIPT been reported previously.[13] Abnormal gait was not considered an exclusion criterion in our study, as opinions differ on gait as a reliable indicator of potential cerebellar stroke versus a peripheral mechanism of dizziness.[8-10, 14] More specifically, gait assessment was done in 49% of patients evaluated by the ED physician, while Neurology consultants did 87%. In the
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patients where both the ED and Neurology did a gait exam, there was no correlation of their
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assessments (gait graded on a 4-point scale, see Methods), with a Spearman’s correlation of
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r2=0.17. In the 5 patients that had cerebellar strokes, Neurology consultants documented other exam findings (a negative head impulse test or subtle nystagmus findings for example) that made
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cerebellar stroke more likely,[10-12, 14] but these were not consistently applied to all patients
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seen by Neurology. Seminal cerebellar stroke studies about vestibular head impulse testing and nystagmus were introduced in 2008-2009 (when our study data were being collected),[11, 12]
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and these are now part of the standard Neurological exam when cerebellar stroke is questioned.
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All 5 cerebellar stroke patients had strokes including, or limited to, the medial posterior inferior cerebellar artery (PICA) territory. Stroke to this vascular territory have previously been
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associated with vertigo or dizziness in isolation.[14] Considering the above, with clinical
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presentation of isolated dizziness and significant stroke risk factors, acute brain MRI appears prudent. Though most patients will rapidly recover from small cerebellar strokes,[15]
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confirmation of a posterior circulation stroke changes workup and management, potentially preventing a future stroke event that could easily result in catastrophic brainstem infarct.
1.6 Conclusions:
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ACCEPTED MANUSCRIPT Isolated dizziness is a common presentation and patients with significant stroke factors (possibly focusing on hyperlipidemia and smoking habits) have a significant cerebellar stroke incidence. Gait assessment does not consistently stratify patients with greater stroke risk, so a low threshold
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for brain MRI seems reasonable even with a normal exam.
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1.7 Bibliography
[1] Cappello M, di Blasi U, di Piazza L, Ducato G, Ferrara A, Franco S, Fornaciari M, Sciortino
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A, Tarantino AM, di Blasi S, (1995) Dizziness and vertigo in a department of emergency
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medicine, Eur J Emerg Med. 2(4) 201-11.
[2] Kerber KA, Zahuranec DB, Brown DL, Meurer WJ, Burke JF, Smith MA, Lisabeth LD,
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Fendrick AM, McLaughlin T, Morgenstern LB, (2014) Stroke risk after nonstroke emergency
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department dizziness presentations: a population-based cohort study, Ann Neurol. 75(6) 899907.
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[3] Bailey KE, Sloane PD, Mitchell M, Preisser J, (1993) Which primary care patients with dizziness will develop persistent impairment?, Arch Fam Med. 2(8) 847-52. [4] Lee H, Sohn SI, Cho YW, Lee SR, Ahn BH, Park BR, Baloh RW, (2006) Cerebellar infarction presenting isolated vertigo: frequency and vascular topographical patterns, Neurology. 67(7) 1178-83.
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ACCEPTED MANUSCRIPT [5] Kochanek KD, Xu J, Murphy SL, Minino AM, Kung HC, (2011) Deaths: final data for 2009, Natl Vital Stat Rep. 60(3) 1-116. [6] Williams D, Wilson TG, (1962) The diagnosis of the major and minor syndromes of basilar insufficiency, Brain. 85 741-74.
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manifestation of vertebrobasilar ischemia, Neurology. 47(1) 94-7.
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[7] Gomez CR, Cruz-Flores S, Malkoff MD, Sauer CM, Burch CM, (1996) Isolated vertigo as a
or vascular disease?, Acta Neurol Scand. 91(1) 43-8.
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[8] Norrving B, Magnusson M, Holtas S, (1995) Isolated acute vertigo in the elderly; vestibular
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[9] Kerber KA, Brown DL, Lisabeth LD, Smith MA, Morgenstern LB, (2006) Stroke among
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patients with dizziness, vertigo, and imbalance in the emergency department: a population-based study, Stroke. 37(10) 2484-7. Epub 2006 Aug 31.
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[10] Huang CY, Yu YL, (1985) Small cerebellar strokes may mimic labyrinthine lesions, J
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Neurol Neurosurg Psychiatry. 48(3) 263-5.
[11] Newman-Toker DE, Kattah JC, Alvernia JE, Wang DZ, (2008) Normal head impulse test
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differentiates acute cerebellar strokes from vestibular neuritis, Neurology. 70(24 Pt 2) 2378-85.
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[12] Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE, (2009) HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination
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more sensitive than early MRI diffusion-weighted imaging, Stroke. 40(11) 3504-10. doi: 10.1161/STROKEAHA.109.551234. Epub 2009 Sep 17. [13] Newman-Toker DE, Cannon LM, Stofferahn ME, Rothman RE, Hsieh YH, Zee DS, (2007) Imprecision in patient reports of dizziness symptom quality: a cross-sectional study conducted in an acute care setting, Mayo Clin Proc. 82(11) 1329-40.
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ACCEPTED MANUSCRIPT [14] Kase CS, Norrving B, Levine SR, Babikian VL, Chodosh EH, Wolf PA, Welch KM, (1993) Cerebellar infarction. Clinical and anatomic observations in 66 cases, Stroke. 24(1) 76-83. [15] Kelly PJ, Stein J, Shafqat S, Eskey C, Doherty D, Chang Y, Kurina A, Furie KL, (2001) Functional recovery after rehabilitation for cerebellar stroke, Stroke. 32(2) 530-4.
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[16] Amarenco P, Hauw JJ, (1990) Cerebellar infarction in the territory of the anterior and
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inferior cerebellar artery. A clinicopathological study of 20 cases, Brain. 113(Pt 1) 139-55.
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[17] Kumral E, Kisabay A, Atac C, (2006) Lesion patterns and etiology of ischemia in the anterior inferior cerebellar artery territory involvement: a clinical - diffusion weighted - MRI
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study, Eur J Neurol. 13(4) 395-401.
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Figure Legend
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Figure 1: Study design for isolated dizziness population Figure 2: Brain MRI diffusion-weighted imaging of cerebellar stroke patients (A) with associated
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“history of present illness” and official radiology MRI report (B).
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ACCEPTED MANUSCRIPT Figure 1
Emergency room presentations
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01/01/2005 through 01/01/2010
Excluded (n=38): CNS localizing finding on history or exam by ED physician (not including gait)
Cranial nerve palsy: 10 patients Dysarthria/aphasia: 7 patients Extremity weakness: 10 patients Sensory deficit: 7 patients Extremity weakness and sensory deficit: 4 patients
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Included: Chief complaint of dizziness or vertigo and a brain MRI performed within 48 hours of presentation: 174 patients
Population: 136 patients with isolated dizziness and a brain MRI within 48 hours of presentation
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ACCEPTED MANUSCRIPT Table 1: Demographics and presentation assessment All Patients
Cerebellar strokes
patients 136
5/136 (3.7%)
Mean age (years)
59.8 ± 16.7 n=136
62.2 ± 12.0 n=5
Sex
80 women (59%)
3 women, 2 men
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Patients, n
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56 men (41%) 29.1 ± 5.6 (n=113)
LDL (mg/dL)
114.0 ± 37.1 (n=87)
HDL (mg/dL)
48.8 ± 12.8
LDL/HDL ratio
2.43 ± 0.79
Hemoglobin A1c (%)
6.6 ± 1.33 (n=66)
6.5 ± 1.51 (n=5)
Hypertension (by history or ED values)
104 patients (76%) n=131
4/5 patients (80%)
Coronary artery disease (by history)
18 patients (13.2%)
1/5 patients (20%)
Atrial fibrillation (by history)
4 patients (2.9%)
0/5 patients
Smokers (active or > 30 pack years)
25 patients (22%) n=112
4/5 patients (80%)*
Previous stroke or TIA
17 patients (12.5%) n=136
0/5 patients
35 patients (26%) n=136
0/5 patients
Taking clopidogrel
0 patients (0%) n=136
0/5 patients
Taking warfarin
2 patients (1.5%) n=136
0/5 patients
Gait assessment by ED
44 normal, 23 abnormal, 69 not documented
2 normal, 3 not documented
Gait assessment by Neurology consult
40 normal, 50 abnormal, 13 not documented
2 normal, 3 abnormal
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Taking aspirin
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Mean Body Mass Index
31.21 ± 4.8 (n=5) 153.2 ± 37.8 (n=5) 43.8 ± 13.4 3.63 ± 0.80**
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Body Mass Index, lipid panel, hemoglobin A1c were included if documented at presentation, or within 1 year prior. Smoking habits were included when documented at presentation. T-test was used for continuous variable, Chi-squared test was applied on categorical variables. *p value < 0.01, ** p value < 0.001
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Abbreviations: low density lipoprotein:high density lipoprotein ratio (HDL: LDL); transient ischemic attack (TIA); Emergency Department (ED)
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ACCEPTED MANUSCRIPT Figure 2B ED presentation quotation: Patient#1 “He has a history of vertigo but presents with an acute worsening vertigo episode. Described as the room moving- circles. Gets nauseated. Not particularly associated with motion, but has greatest sense when walking- feels very unsteady#. He also experience tinnitus in both ears% (this is new for him over past few days). The dizziness seem random to the patient, but walking is most difficult#.”
MRI report: There is an area of restricted diffusion on the posterior right cerebellum and also a smaller focus of restricted diffusion within the lateral aspect of the right cerebellum and the superior aspect of the left cerebellum. These findings are consistent with recent subacute infarcts. There is associated T2 and FLAIR signal hyperintensity with these lesions.
Patient#2 “4 days of constant lightheadedness, episodic dizziness feeling like the room is spinning$, nausea, brief episodes of sharp substernal chest pain. Her lightheadedness has persisted and is not related to positioning. She states that her legs gave out and she fell to the floor twice this weekend#. She states she felt a similar episode coming on today at work, but was able to brace herself against a wall and not fall.”
There are several foci of restricted diffusion consistent with recent infarcts in the bilateral cerebellar hemispheres. No other areas of restricted diffusion identified. There are 2 areas of FLAIR hyperintensities within the right cerebellum, which are stable since the prior MRI.
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Patient#3 “For the past week he has been having posterior neck pain which radiates to the back of his skull causing him moderate headache *….awoke, feeling "dizzy", room was spinning, he had to grab hold of walls to walk and felt very unbalanced.#,$ He normally uses a cane at baseline due to peripheral neuropathy, however claims his gait today is not his normal# ”
There is restricted diffusion in the left inferior medial cerebellum, with associated abnormal T2 and FLAIR signal, consistent with a recent infarct.
Patient#4 “She came in to the ED with a chief complaint of unsteadiness# and dizziness for several days. Now she is feeling much better, almost back to baseline. ”
Multiple foci of restricted diffusion with associated T2/FLAIR hyperintense signal are noted within the right cerebellar hemisphere more so in a posterior-inferior distribution consistent with a recent right PICA infarct. Multiple foci of small regions of susceptibility-related signal loss are seen within this infarct in the right
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ACCEPTED MANUSCRIPT cerebellar hemisphere consistent with blood products.
Patient#5 “Awoke at 3 am on Thanksgiving and felt that the whole room was spinning. She also noted a headache*, especially over the right side of the head/ear and increased ringing in her ear% (though she states that she has endured tinnitus in her ears for years).”
There are two small foci of restricted diffusion within the inferior medial aspect of the right cerebellar hemisphere consistent with acute infarct involving the vascular territory of the right PICA.
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# Gait complaints on a dizzy presentation make cerebellar stroke more likely; 4,14 a 4-fold higher risk9
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% Cerebellar strokes can present with tinnitus, especially with anterior inferior cerebellar artery (AICA) territory strokes
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* Headache is a common comorbid complaint with cerebellar strokes, present in approximately 50% of cases 14
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$ Nonspecific dizzy complaints (including lightheaded, vertigo, imbalance) are common 13
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