Cerebellar Infarct Presenting Cerebellar Infarct Presenting with Isolated Vertigowith Isolated Vertigo

Cerebellar Infarct Presenting Cerebellar Infarct Presenting with Isolated Vertigowith Isolated Vertigo

Kam A. Newman, M.D.Saeed Kahkeshani, M.D.San Jacinto Methodist HospitalBaytown, TX

Kam A. Newman, M.D.Saeed Kahkeshani, M.D.San Jacinto Methodist HospitalBaytown, TX

Case SummaryCase SummaryCase SummaryCase Summary The pt is a 54 year old Caucasian female whoThe pt is a 54 year old Caucasian female whofound violent vomiting all of sudden and lasted afound violent vomiting all of sudden and lasted acouple of days. She was admitted hospital forcouple of days. She was admitted hospital forprofuse vomiting and sever weakness. She denies anyprofuse vomiting and sever weakness. She denies anychest pain, SOB, palpitation, vision problem, andchest pain, SOB, palpitation, vision problem, andabdominal pain. All lab works were normal exceptabdominal pain. All lab works were normal exceptLipase 1778, and Amylase 252. Pt discharged withLipase 1778, and Amylase 252. Pt discharged withDiagnosis of probable pancreatitis. Diagnosis of probable pancreatitis. Pt got back to ER with altered mental status, andPt got back to ER with altered mental status, andpersistent vomiting. An MRI of the brainpersistent vomiting. An MRI of the brainconfirmed subacute cerebellar infarction.confirmed subacute cerebellar infarction.

The pt is a 54 year old Caucasian female whoThe pt is a 54 year old Caucasian female whofound violent vomiting all of sudden and lasted afound violent vomiting all of sudden and lasted acouple of days. She was admitted hospital forcouple of days. She was admitted hospital forprofuse vomiting and sever weakness. She denies anyprofuse vomiting and sever weakness. She denies anychest pain, SOB, palpitation, vision problem, andchest pain, SOB, palpitation, vision problem, andabdominal pain. All lab works were normal exceptabdominal pain. All lab works were normal exceptLipase 1778, and Amylase 252. Pt discharged withLipase 1778, and Amylase 252. Pt discharged withDiagnosis of probable pancreatitis. Diagnosis of probable pancreatitis. Pt got back to ER with altered mental status, andPt got back to ER with altered mental status, andpersistent vomiting. An MRI of the brainpersistent vomiting. An MRI of the brainconfirmed subacute cerebellar infarction.confirmed subacute cerebellar infarction.

MRCPMRCPMRCPMRCP

Top normal hepatic common bile duct with no filling defects or morphologicabnormality.

Top normal hepatic common bile duct with no filling defects or morphologicabnormality.

Abrupt tapering of the distal commonbile duct with a distal Short segment ofprominent narrowing.

Abrupt tapering of the distal commonbile duct with a distal Short segment ofprominent narrowing.

MRI of the Brain MRI of the Brain MRI of the Brain MRI of the Brain

Diffusion studies demonstrates increased signal in the posterior portion of both cerebellar hemispheres consistent with subacute cerebellar infarction.

Diffusion studies demonstrates increased signal in the posterior portion of both cerebellar hemispheres consistent with subacute cerebellar infarction.

MRI of the Brain (Cont)MRI of the Brain (Cont)MRI of the Brain (Cont)MRI of the Brain (Cont)

ADC mapping demonstrates areas of decreased signal In both cerebellar hemisphere. ADC mapping demonstrates areas of decreased signal In both cerebellar hemisphere.

MRI of the Brain (Cont)MRI of the Brain (Cont)

T2 axial consistent with increased signal within theBoth cerebellar hemisphere.T2 axial consistent with increased signal within theBoth cerebellar hemisphere.

MRI of the Brain (Cont)MRI of the Brain (Cont)MRI of the Brain (Cont)MRI of the Brain (Cont)

T2 weight FLAIR demonstrates increased signal in both Both cerebellar hemisphere.T2 weight FLAIR demonstrates increased signal in both Both cerebellar hemisphere.

MRI of the Brain (Cont)MRI of the Brain (Cont)MRI of the Brain (Cont)MRI of the Brain (Cont)

T1 axial shows decreased signal within both cerebellarHemispheres.T1 axial shows decreased signal within both cerebellarHemispheres.

DefinitionsDefinitionsDefinitionsDefinitions Stroke: Sudden death of a portion of the brain cells due Stroke: Sudden death of a portion of the brain cells due

to a lack of oxygen.to a lack of oxygen.

Dizziness (Lightheadedness): A sensation of altered Dizziness (Lightheadedness): A sensation of altered spatial orientation.spatial orientation.

Vertigo: Any abnormal sensation of motion between a Vertigo: Any abnormal sensation of motion between a patient and the surroundings.patient and the surroundings.

Disequilibrium (Imbalance): Patients may feel normal Disequilibrium (Imbalance): Patients may feel normal when they are stationary, but notice difficulty when they when they are stationary, but notice difficulty when they walk.walk.

Stroke: Sudden death of a portion of the brain cells due Stroke: Sudden death of a portion of the brain cells due to a lack of oxygen.to a lack of oxygen.

Dizziness (Lightheadedness): A sensation of altered Dizziness (Lightheadedness): A sensation of altered spatial orientation.spatial orientation.

Vertigo: Any abnormal sensation of motion between a Vertigo: Any abnormal sensation of motion between a patient and the surroundings.patient and the surroundings.

Disequilibrium (Imbalance): Patients may feel normal Disequilibrium (Imbalance): Patients may feel normal when they are stationary, but notice difficulty when they when they are stationary, but notice difficulty when they walk.walk.

StatisticsStatisticsStatisticsStatistics Stroke, after heart disease and cancer, is the third commonest Stroke, after heart disease and cancer, is the third commonest

cause of death in the U.S.cause of death in the U.S.

- Killed 150,074 people in 2004.Killed 150,074 people in 2004.- About 780.000 people suffer a new or recurrent stroke each year.About 780.000 people suffer a new or recurrent stroke each year.

- Almost every 45 seconds in the U.S, a person experiences stroke.Almost every 45 seconds in the U.S, a person experiences stroke.

- Stroke is the leading cause of disability among adults in the U.S.Stroke is the leading cause of disability among adults in the U.S.

Stroke, after heart disease and cancer, is the third commonest Stroke, after heart disease and cancer, is the third commonest cause of death in the U.S.cause of death in the U.S.

- Killed 150,074 people in 2004.Killed 150,074 people in 2004.- About 780.000 people suffer a new or recurrent stroke each year.About 780.000 people suffer a new or recurrent stroke each year.

- Almost every 45 seconds in the U.S, a person experiences stroke.Almost every 45 seconds in the U.S, a person experiences stroke.

- Stroke is the leading cause of disability among adults in the U.S.Stroke is the leading cause of disability among adults in the U.S.

Statistics (Cont)Statistics (Cont)Statistics (Cont)Statistics (Cont)

Dizziness:Dizziness: No definitive statistics exist about No definitive statistics exist about vertigo/dizziness/imbalance.vertigo/dizziness/imbalance.

- Over 90 million Americans, age 17 and older have Over 90 million Americans, age 17 and older have experienced a dizziness or balance problem.experienced a dizziness or balance problem.

- Dizziness is a common symptom affecting about 30% of Dizziness is a common symptom affecting about 30% of people over the age 65.people over the age 65.

- In the general population (all ages), 347.000 hospital days In the general population (all ages), 347.000 hospital days per year in the U.S. are incurred because of “vertiginous per year in the U.S. are incurred because of “vertiginous syndromes”.syndromes”.

Dizziness:Dizziness: No definitive statistics exist about No definitive statistics exist about vertigo/dizziness/imbalance.vertigo/dizziness/imbalance.

- Over 90 million Americans, age 17 and older have Over 90 million Americans, age 17 and older have experienced a dizziness or balance problem.experienced a dizziness or balance problem.

- Dizziness is a common symptom affecting about 30% of Dizziness is a common symptom affecting about 30% of people over the age 65.people over the age 65.

- In the general population (all ages), 347.000 hospital days In the general population (all ages), 347.000 hospital days per year in the U.S. are incurred because of “vertiginous per year in the U.S. are incurred because of “vertiginous syndromes”.syndromes”.

Vertigo, Classification and CausesVertigo, Classification and CausesVertigo, Classification and CausesVertigo, Classification and Causes

Peripheral: A short or episodic time course, a precipitating factor, Peripheral: A short or episodic time course, a precipitating factor, and the presence of autonomic symptoms.and the presence of autonomic symptoms.

- Benign paroxysmal positional vertigo- Benign paroxysmal positional vertigo

- Vestibular Neuritis (VN) - Meniere disease - Vestibular Neuritis (VN) - Meniere disease - Labyrinthine ischemia or hemorrhage/Cholesteatoma- Labyrinthine ischemia or hemorrhage/Cholesteatoma

- Acute alcohol intoxication - Ototoxicity/Otosclerosis- Acute alcohol intoxication - Ototoxicity/Otosclerosis

- Metabolic Disorders - Metabolic Disorders

Peripheral: A short or episodic time course, a precipitating factor, Peripheral: A short or episodic time course, a precipitating factor, and the presence of autonomic symptoms.and the presence of autonomic symptoms.

- Benign paroxysmal positional vertigo- Benign paroxysmal positional vertigo

- Vestibular Neuritis (VN) - Meniere disease - Vestibular Neuritis (VN) - Meniere disease - Labyrinthine ischemia or hemorrhage/Cholesteatoma- Labyrinthine ischemia or hemorrhage/Cholesteatoma

- Acute alcohol intoxication - Ototoxicity/Otosclerosis- Acute alcohol intoxication - Ototoxicity/Otosclerosis

- Metabolic Disorders - Metabolic Disorders

Vertigo (Cont)Vertigo (Cont)Vertigo (Cont)Vertigo (Cont)

Central: Associated neurologic symptoms are diplopia, Central: Associated neurologic symptoms are diplopia, hemianopsia, weakness, numbness, dysarthria, ataxia, and hemianopsia, weakness, numbness, dysarthria, ataxia, and loss of consciousness.loss of consciousness.

- Vascular disease - Migraine - Seizure disorder Vascular disease - Migraine - Seizure disorder

- Cerebellar degeneration syndromes - Multiple sclerosisCerebellar degeneration syndromes - Multiple sclerosis

- Disorders of the craniovertebral junctionDisorders of the craniovertebral junction

- Neurologic complications of ear infectionsNeurologic complications of ear infections

Central: Associated neurologic symptoms are diplopia, Central: Associated neurologic symptoms are diplopia, hemianopsia, weakness, numbness, dysarthria, ataxia, and hemianopsia, weakness, numbness, dysarthria, ataxia, and loss of consciousness.loss of consciousness.

- Vascular disease - Migraine - Seizure disorder Vascular disease - Migraine - Seizure disorder

- Cerebellar degeneration syndromes - Multiple sclerosisCerebellar degeneration syndromes - Multiple sclerosis

- Disorders of the craniovertebral junctionDisorders of the craniovertebral junction

- Neurologic complications of ear infectionsNeurologic complications of ear infections

Vestibular NeuritisVestibular NeuritisVestibular NeuritisVestibular Neuritis

The second most common dizziness diagnosis in The second most common dizziness diagnosis in general practice after BPPV.general practice after BPPV.

Often erroneously called acute or viral labyrintitis.Often erroneously called acute or viral labyrintitis.

By definition, pts with VN have a unilateral By definition, pts with VN have a unilateral decreased caloric response and the head trust test is decreased caloric response and the head trust test is almost always abnormal toward the side of the lesion.almost always abnormal toward the side of the lesion.

The second most common dizziness diagnosis in The second most common dizziness diagnosis in general practice after BPPV.general practice after BPPV.

Often erroneously called acute or viral labyrintitis.Often erroneously called acute or viral labyrintitis.

By definition, pts with VN have a unilateral By definition, pts with VN have a unilateral decreased caloric response and the head trust test is decreased caloric response and the head trust test is almost always abnormal toward the side of the lesion.almost always abnormal toward the side of the lesion.

Classification of StrokeClassification of StrokeClassification of StrokeClassification of Stroke

Symptoms of StrokeSymptoms of StrokeSymptoms of StrokeSymptoms of Stroke

SymptomIschemic Stroke

(%) ICH (%) SAH (%)

Headache 11–17 33–41 78–87

Vomiting 8–11 29–46 45–48

Decreased LOC 13–15 39–57 48–68

Seizure 0.3–3 6–7 7

Clinical FeaturesClinical FeaturesClinical FeaturesClinical Features

Headache at onset is an invariable feature of SAH, also Headache at onset is an invariable feature of SAH, also common in patients with large ICHs. Headache is rare in common in patients with large ICHs. Headache is rare in lacunar infarcts.lacunar infarcts.

Vomiting is very common in SAH, ICH, and with brain Vomiting is very common in SAH, ICH, and with brain stem and cerebellar infarcts.stem and cerebellar infarcts.

Seizures at or soon after the stroke are common in patients Seizures at or soon after the stroke are common in patients with lobar hemmorhages, and brain embolisms, but are with lobar hemmorhages, and brain embolisms, but are rare in lacunar infarcts.rare in lacunar infarcts.

Headache at onset is an invariable feature of SAH, also Headache at onset is an invariable feature of SAH, also common in patients with large ICHs. Headache is rare in common in patients with large ICHs. Headache is rare in lacunar infarcts.lacunar infarcts.

Vomiting is very common in SAH, ICH, and with brain Vomiting is very common in SAH, ICH, and with brain stem and cerebellar infarcts.stem and cerebellar infarcts.

Seizures at or soon after the stroke are common in patients Seizures at or soon after the stroke are common in patients with lobar hemmorhages, and brain embolisms, but are with lobar hemmorhages, and brain embolisms, but are rare in lacunar infarcts.rare in lacunar infarcts.

Cerebellar Infarct and VertigoCerebellar Infarct and VertigoCerebellar Infarct and VertigoCerebellar Infarct and Vertigo

Topographic Distribution of Cerebellar Topographic Distribution of Cerebellar InfarctsInfarcts

Topographic Distribution of Cerebellar Topographic Distribution of Cerebellar InfarctsInfarcts

Vertigo Work upVertigo Work upVertigo Work upVertigo Work up

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