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CASE 18.1

A 75-year-old right-handed man presents to the emergency department (ED) with dizziness that started 5 hours ago. His dizziness consists of a spinning sensation and he feels off balance as he walks. He reports coughing when trying to drink water earlier, but otherwise notes no other symptoms. He has an unremarkable past medical history and is taking no medications. On examination, he is found to have left-sided ptosis and left facial numbness to pinprick. Gag reflex is absent. Motor examination is otherwise unremarkable. Sensory examination revealed decreased pinprick sensation of the right arm and leg. He is unsteady while walking, tending to lean leftward.

Question 18.1.1 What is the most likely diagnosis in this patient?

A) Acute vestibulitis/labyrinthitis

B) Benign paroxysmal positional vertigo (BPPV)

C) Cerebellar stroke

D) Brain stem stroke

E) Ménière attack

Answer 18.1.1 The correct answer is "D." Although dizziness can be associated with all of the above disorders, a brain stem stroke is the most likely answer. The associated symptoms of ptosis (suggestive of Horner syndrome), absent gag reflex with patient report of possible dysphagia, and crossed sensory findings (left side face, right side body) are most consistent with brain stem localization. In peripheral etiologies of vertigo ("A," "B," and "E"), one would not expect sensory phenomena, ptosis, or swallowing difficulties. In BPPV, one would expect brief attacks, lasting seconds to minutes, and not a prolonged attack. In Ménière's, there is often some history of tinnitus and/or hearing loss (low frequency initially). A pure cerebellar stroke would not be expected to have sensory findings.

Image not available. HELPFUL TIP:

When a patient complains of dizziness, ask what the patient means by "dizziness." The term "dizziness" means different things to different patients. "Dizziness" may represent vertigo, lightheadedness, pre-syncope, disequilibrium when walking (e.g., falling to one side), anxiety, etc. Also, know that there is controversy among experts as to whether this delineation of dizziness is more misleading than it is helpful.

In conferring with your colleague, she asks if you are going to give tissue plasminogen activator (tPA).

Question 18.1.2 Which one of the following is NOT a contraindication to intravenous (IV) tPA?

A) Age >75

B) INR >1.7

C) Platelets <100,000

D) Stroke within last 3 months

E) Glucose <50

F) Hemorrhage seen on head CT

Answer 18.1.2 The correct answer is "A." Acute stroke treatment with ...

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