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 w/ acute vestibular syndrome (e.g. labyrinthitis)

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