An 80-year-old man presents to the Emergency Department reporting that he awoke this morning with dizziness and vomiting. On further questioning, you establish that he has a sensation of the room spinning around him, which is worse when he moves his head quickly, although persists with his head still, and that he vomits when these symptoms are at their most severe. He is unsteady on his feet and staggers when you try to walk him around his bed. He has no other symptoms or signs. He has a past medical history of hypertension, high cholesterol, type II diabetes which is diet controlled, and osteoarthritis.
Which of the following diagnoses is it most important to exclude?
Posterior circulation stroke
Postural hypotension
Benign paroxysmal positional vertigo
Meningo-encephalitis
Viral labyrinthitis
Dr. Kasper:
Posterior circulation stroke
Posterior circulation stroke must always be considered as a differential in a patient presenting with acute vertigo
A central cause of vertigo must always be considered. Central causes include posterior circulation stroke, acoustic neuroma and other benign and malignant brain tumours, and multiple sclerosis. Stroke is the most urgent diagnosis to make, and the most likely in this patient with cardiovascular risk factors.
A posterior circulation stroke affects the brain tissue supplied by the vertebral, basilar or posterior cerebral arteries - which includes the brainstem, cerebellum, thalamus, midbrain, and parts of the temporal and occipital cortex. Posterior circulation strokes account for 20-25% of ischaemic strokes in the UK but are more difficult to diagnose than anterior circulation strokes. Symptoms can include dizziness, vomiting, double vision, dysarthria, dysphagia, ataxia, limb weakness and visual field defects.