What’s Your Diagnosis? Patient With Acute Dizziness
November 29, 2019


Posted by Andy Jagoda, MD in: What's Your Diagnosis , trackback

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Case Presentation: A previously healthy man with dizziness

The day shift signs out to you a 44-year-old previously healthy man. He is currently at CT.

His dizziness started 6 hours previously and has been present ever since. He describes unsteadiness and ?feeling like I am drunk,? and has vomited 3 times. He denies headache or neck pain, weakness, or numbness. His vital signs are normal. There is some left-beating horizontal nystagmus in primary gaze and in leftward gaze. The head impulse test is normal.

The sign-out is that if his CT scan is normal, he can go home with meclizine and follow-up with his PCP in 2 days.

That sounds reasonable, but you wonder if there is something else that needs to be considered…

Case Conclusion

You are NOT OK with the plan for discharge if the man?s CT is normal. His CT was normal, but sensitivity of noncontrast head CT in early posterior circulation stroke is very low and a negative CT should never reassure physicians that they have ruled out ischemic stroke. The absence of a report of ?vertigo? is diagnostically meaningless. Although his nystagmus is consistent with a peripheral problem, it is also consistent with a central problem, so completing the bedside examination for a patient with an AVS is important. Calling the HIT ?normal? is also problematic. ?Normal? means the absence of a corrective saccade, which in the setting of the AVS is worrisome for stroke. Better terminology would be that HIT is ?worrisome? or ?reassuring,? and better yet, ?absence or presence of a corrective saccade.? Since physical examination
is more sensitive than even early MRI for posterior circulation stroke presenting as isolated dizziness, this patient was admitted for a stroke workup.

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Comments »

1. Doug carroll - December 2, 2019

Leftward gaze not ok

2. Musab alkhateeb - December 12, 2019

Cerebellar stroke

3. Amr ismail - December 12, 2019

Cerebellur infarction that May take time to appear on initial CT head scans , needs more evaluation for vertigo in terms of associated hearing symptoms , Dix hallpike testing , signs for cerebellar pathology should be tested

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