Isolated vertigo within the time window, should venous thrombolysis be considered?

*For medical professionals only

A detailed physical examination is essential

Author's note

Isolated vertigo (IV) refers to vertigo caused by various factors without hearing loss and neurological localization symptoms and signs, which can be accompanied by gait instability and nausea, vomiting, and nystagmus [1].


In fact, lesions from peripheral labyrinth to the center can lead to IV, and clinically, especially CT scan negative central vasogenic isolated vertigo (CVIV) diagnosis is difficult, often prone to misdiagnosis/omission, and emergency management is also very tricky, especially IV
within the time window.

For neurologists, the decision is more tangled, and whether to intravenous thrombolysis is a very difficult choice
.
Just think, if the cerebrovascular malignant event occurs without thrombolysis, it will cause poor prognosis of the patient, or even death
.





Recently, the department admitted 1 patient with sudden dizziness with nausea and vomiting, and no other complaints and signs
.

The patient, a 52-year-old male, came to the emergency department
for "sudden dizziness with vomiting for 3.
5 hours".

Current medical history: 3.
5 hours before the self-reported sudden dizziness without inducement, accompanied by visual rotation, nausea, vomiting a large number of gastric contents
.
Can still eat water, can hold things, can not walk, no tinnitus, no limb weakness, no headache and drinking water cough, no fever and convulsions, consciousness disorders, speech is unfavorable
.
Symptoms continue to not ease, come to our hospital emergency
.
There was no obvious abnormality in the CT scan of the skull, and the neurology department was consulted, and the "cause of dizziness" was proposed to be the main diagnosis and admitted to the hospital
.
Before the onset of this illness, there was a history of upper respiratory tract infection, the disease came to be delirious, soft, diet and sleep in general, normal bowel and bladder, and no significant change in
weight.

Past history: "hypertension" history for several years, blood pressure up to 160/90mmHg, irregular taking of "amlodipine besylate tablets, 1 tablet/time, 1 time/day", blood pressure control can be; 3 years history of type 2 diabetes mellitus, but not treated with medication; Denial of history of coronary heart disease, denial of history of infectious diseases such as hepatitis and tuberculosis, denial of history of major trauma, denial of surgical history, denial of blood transfusion history
.
There is no obvious history of
drug or food allergies.
No smoking, alcohol or other bad habits
.

Physical examination: T: 36.
5, P: 78 times/min, R: 14 times/min, BP: 144/87 mmHg (left), 148/92 mmHg (right); Cardiopulmonary examination did not reveal significant abnormalities
.
Advanced cortex: conscious, fluent in speech, character orientation, location orientation, time orientation, computing power normal, right hand
.

Cranial nerve: large isocircles of bilateral pupils, diameter 3 mm, sensitive to light reflexes, no nystagmus in both eyes; The frontal lines are symmetrical on both sides, the nasolabial folds are symmetrical on both sides, the tongue is mediated, and the gag reflex is present
.

Exercise and Mutual Assistance: the muscle tone of the limbs is normal, the finger and nose test is stable, the shin test is stable and accurate, and the Mutual Aid movement is
stable.
Sensory system: there is no obvious abnormality
in the depth and superficial sensory examination.

Reflexes: tendon reflexes of the extremities present (++), bilateral Babinski (-), bilateral Chaddock(-), meningeal irritation signs (-).

The National Institutes of Health had a score of 0 for neurological deficits (NIHSS), a grade of 1 in the Drinking Water Test in the Depression Field, and a score of 1 on
the Modified Rankin Scale (mRS).

Complete the adjunctive examination as follows, CT excludes bleeding
.

Figure 1: No abnormal changes in size, morphology and density of bilateral cerebral hemispheres and cerebellum (2022.
7.
31) Combined with the above data, preliminary diagnosis: (1)




Dizziness cause: vestibular neuritis? Posterior circulation ischemia? (2) Hypertension grade 2 is very high-risk; (3) Type 2 diabetes
.

Oxygen inhalation, ECG monitoring, conventional doses of anti-platelet aggregation, anti-arteriosclerosis, improvement of circulation, nerve nutrition, blood pressure and blood glucose control, and symptomatic supportive treatment
.

However, the next day, a flat MRI of the patient's skull showed a large-scale cerebral infarction of the right side of the cerebellum, and a loading dose was given to prevent platelet aggregation and anti-arteriosclerosis, dehydration and lowering cranial pressure, and neurosurgical consultation
was requested in time.
Bone flap decompression surgery
is performed with the written consent of the family.

Figure 2: Cerebellar large abnormal signal, mainly on the right side, T1WI low signal, T2WI, FLAIR, DWI high signal (2022.
8.
1)

Figure 3: (Left panel) Large-scale low-density shadow is seen in the cerebellum, the right side is the shadow, a little high-density shadow and multiple gas density shadow are seen in the operative area, and the drainage catheter shadow is also seen, and the occipital bone part is absent (2022.
8.
3)

(Right) The cerebellum sees a large mixed density shadow, which is mainly low density, and the patchy high-density shadow inside it is absorbed
compared with the front.
Ochiopsal bone partial absence, slightly enlarged fourth ventricle (2022.
8.
25)

In clinical practice, the diagnosis of vertigo with otological or neurological signs is relatively easy, but patients with IV symptoms often cause great confusion
for physicians when making a diagnosis.
As can be seen from the diagnosis and treatment process of this patient, the diagnosis of CVIV is extremely challenging
.

IV is likely to be benign positional vertigo, Meniere's disease, vestibular neuronitis, these diseases are often significantly improved after symptomatic treatment; However, there is also the possibility of posterior circulation infarction, if it is not treated in time and effectively, the prognosis is poor
.

▌ Should IV be considered for venous thrombolysis? According to the existing clinical experience and literature references, if the patient has only vertigo symptoms and no posterior circulatory signs are found on physical examination, the National Institutes of Health Stroke Scale (NIHSS) score may have a low score, and there is no previous history of similar seizures, and no obvious abnormalities
in head CT.
Then, although patients have risk factors such as hypertension and diabetes, venous thrombolysis can be ignored and dual antibody therapy
is given first.
However, other symptom changes should be closely observed, and regular neurological examinations should be carried out
in a timely manner.

Cerebral infarction should be considered if accompanied by ataxia, dysarthria, sensory impairment, and decreased muscle strength
.
Hospitals with the capacity should complete imaging tests as soon as possible, especially MRI, CTP, and head and neck CTA[2
].

Some patients complain of only vertigo, no obvious abnormalities on physical examination, but there may be large-scale hypoperfusion of the posterior circulation blood supply area or posterior circulating vascular abnormalities visible on CTA, etc.
The treatment plan of this patient can be more active, including intravenous thrombolysis and endovascular intervention
.





In the emergency department, the patient's main complaint is only vertigo when the clinician needs to make a detailed physical examination, and trace the previous history of similar seizures and closely observe the changes in the condition, and give corresponding treatment
in time.

Of course, many times it is necessary to strengthen full communication with family members, inform risks, and avoid unnecessary medical disputes
as much as possible.

References:

Liu Jiali,Qiu Jianting.
Posterior circulation ischemia manifested as isolated acute vestibular syndrome[J].
Chinese Journal of Geriatric Cardiocerebrovascular Diseases,2019,21(3):290-293.

[2] Kim HA,Lee H,Kim JS.
Vertigo due to vascular mechanisms[J].
Semin Neurol,2020,40(1):67-75.

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Source of this articleMedical Neurology ChannelYu Zhi Department of Neurology, First People's Hospital of Chun'an County, Zhejiang ProvinceLi Tuming, Deputy Chief Physician
Responsible EditorMr.
Lu Li Xiang Yu

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