Cerebellar stroke

Clinical Features

• Sudden inability to walk is common finding
• May have additional signs of of Posterior Circulation Stroke- 5Ds: Dizziness (Vertigo), Dysarthria, Dystaxia, Diplopia, Dysphagia
• Can be confused with acute vestibular syndrome (e.g. labyrinthitis)

Central vs. Peripheral Causes of Vertigo

	Peripheral	Central
Onset	Sudden	Sudden or slow
Severity	Intense spinning	Ill defined, less intense
Pattern	Paroxysmal, intermittent	Constant
Aggravated by position/movement	Yes	Variable
Nausea/diaphoresis	Frequent	Variable
Nystagmus	Horizontal and unidirectional	Vertical and/or multidirectional
Fatigue of symptoms/signs	Yes	No
Hearing loss/tinnitus	May occur	Does not occur
Abnormal tympanic membrane	May occur	Does not occur
CNS symptoms/signs	Absent	Usually present

Differential Diagnosis

Vertigo

• Vestibular/otologic
  • Benign paroxysmal positional vertigo (BPPV)
  • Traumatic (following head injury)
  • Infection
    • Labyrinthitis
    • Vestibular neuritis
    • Ramsay Hunt syndrome
  • Ménière's disease
  • Ear foreign body
  • Otic barotrauma
  • Otosclerosis
• Neurologic
  • Cerebellar stroke
  • Vertebrobasilar insufficiency
  • Lateral Wallenberg syndrome
  • Anterior inferior cerebellar artery syndrome
  • Neoplastic: cerebellopontine angle tumors
  • Basal ganglion diseases
  • Vertebral Artery Dissection
  • Multiple sclerosis
  • Infections: neurosyphilis, tuberculosis
  • Epilepsy
  • Migraine (basilar)
• Other
  • Hematologic: anemia, polycythemia, hyperviscosity syndrome
  • Toxic
    • Alcohol
    • Aminoglycosides
  • Chronic renal failure
  • Metabolic
    • Thyroid Disease
    • Hypoglycemia

Diagnosis

Exam

• HINTS Exam can reliably distinguish the two (more effective than early DWI MRI)
  • 1. Head Impulse Testing
    • Tests vestibulo-ocular reflex
    • Have pt fix their eyes on your nose
    • Move their head in the horizontal plane to the left and right
    • If reflex is intact their eyes will stay fixed on your nose
    • If reflex is abnormal eyes will move with their head and won't stay fixed on your nose
    • It is reassuring if the reflex is abnormal!(due to dysfunction of the nerve)
  • 2. Nystagmus
    • Benign nystagmus only beats in one direction no matter which direction their eyes look
    • Central nystagmus beats in multiple directions, is less likely to fatigue, and should be reproducible
      • If pt looks left, get left nystagmus, if looks right, get right-beating nystagmus
  • 3. Test of Skew
    • Vertical dysconjugate gaze is bad
    • Alternating cover test
      • Have pt look at your nose w/ their eyes and then cover one eye
        • When rapidly uncover the eye look to see if the eye quickly moves to re-align
  • If any of the above 3 tests are consistent w/ CVA obtain full work-up (including MRI)

Work-Up

1. Bedside glucose
2. Bedside Hb (polycythemia)
3. CBC
4. Chemistry
5. Coags
6. Troponin
7. ECG (esp A-fib)
8. Head CT
   1. Primarily used to exclude intracranial bleeding, abscess, tumor, other stroke mimics
9. Also consider:
   1. Pregnancy test
   2. CXR (if infection suspected)
   3. UA (if infection suspected)
   4. Utox (if ingestion suspected

Management

• Early neurosurgical consultation is needed (herniation may lead to rapid deterioration)
• See Stroke (Main)
• See Thrombolysis in Acute Ischemic Stroke (tPA)

See Also

• Stroke syndromes
• Vertigo