HPI

• 59 y.o. African-American male presents with complaints of 24 hours of nausea, vomiting, lightheadedness, left ear hearing loss, and gait instability.
• Felt “lightheadedness” at work, then developed vomiting and felt unsteady on his feet
• Has vomited numerous times over the past 24 hours.
• No focal numbness, weakness, or vision change.
• Also notes mild headache that comes and goes.

Pmhx: NIDDM, HTN

Physical Exam

• Vitals: BP 222/100 | Pulse (!) 48 | Temp 97.5 °F | Resp 16 | SpO2 100% | BMI 26.85 kg/m² FSBS 270
• General: appears uncomfortable, vomiting
• HEENT: TMs clear bilaterally, EOMI. Hearing intact bilaterally
• Neck: Normal range of motion. Neck supple.
• Cardiovascular: Bradycardic, no murmurs
• Pulmonary/Chest: Effort normal. No respiratory distress.
• Abdominal: Soft. He exhibits no distension. There is no tenderness.
• Neurological: He is alert and oriented to person, place, and time. No cranial nerve deficit or sensory deficit. He exhibits normal muscle tone. Coordination normal. 5/5 all extremities, normal sensation all extremities, Finger to nose normal, heel to shin normal, normal rapid alternating movements. Refused ambulatory test given active emesis.

DDx

• The differential diagnosis for dizziness/gait instability and vomiting is wide and includes a mix of benign as well as catastrophic pathology
• ICH or mass
• Abdominal pathology causing vomiting and attendant dehydration with dizziness: viral enteritis/SBO/pancreatitis/hepatitis)
• DKA
• Peripheral vertigo will often present with "dizziness" and vomiting
• Posterior circulation stroke
• PRES “posterior reversible encephalopathy syndrome”

Work up

• CT head: There are chronic appearing lacunar infarcts in the left external capsule and the left posterior limb of the internal capsule. There are scattered foci of hypodensity in the periventricular and subcortical white matter, which are nonspecific but suggestive of microvascular ischemic disease of indeterminate age. There is no acute intracranial hemorrhage, intra or extra-axial fluid collection, midline shift or herniation.
• CTA head and neck: The major vessels arising from the aortic arch are widely patent. A bovine trunk is noted. There is nonvisualization of the left vertebral artery. The right vertebral artery appears patent. Reconstitution of the distal left vertebral artery is noted which may be from retrograde flow. Both common carotid arteries and carotid bifurcations are normal. The distal internal carotid arteries are widely patent. The basilar artery is patent but diminutive. There is minimal flow in the posterior cerebral arteries. Some contribution of flow of the left posterior cerebral artery from the internal carotid artery is noted. The anterior and middle cerebral arteries are also diminutive but patent. There is mild stenosis of the left mid M1 segment of the middle cerebral artery. There is no cutoff of the intracranial vessels. No obvious aneurysm or vascular malformation is identified.

ED treatment and clinical course

• Consults to neurology and interventional neurology
• Admitted to ICU for monitoring and BP control
• Subsequently developed R sided hemiparesis A STAT MRI showed left sided pontine infarct
• Patient taken for to neuro-interventional suite and had stenting of basilar artery

TAKE HOME POINTS

• Remember posterior circulation infarct or arterial insufficiency as a potential cause for “dizziness” or vertigo
• Posterior circulation stroke symptoms: ataxia (gait and/or limb), nystagmus, altered mental status, dizziness with or without vertigo, N/V, CN abnormalities, headache, dysarthria, diplopia,, dysphagia
• Posterior circulation stroke can also cause unilateral limb weakness; however motor dysfunction can be minimal, which can falsely reassure patients and physicians alike that the patient is not having an acute stroke