Medical Excellence- Issue 1

An Unusual Case of Vertigo: The Usefulness of Nystagmus Examination Carlotta Casati 1 , Matteo Castelli 1 , Andrea Pavellini 1 , Cosimo Caviglioli 1 , Rudi Pecci 2 A 50-year-old gardener presented to our Emergency Department (ED) after the onset of a sudden objective vertigo while standing up during work, accompanied by imbalance, nausea, and vomiting. Neither tinnitus nor other aural symp- toms were present, but, if asked, he also complained of a mild headache. He had no medical background of interest except for a known hypertension, left untreated, and a possible history of migraine for which he was admitted to the ED 1 year before. He denied recent viral infections or trauma. He was an active smoker (35 pack years), but denied alcohol or sympathomi- metic intake; he was not taking any medication and had no al- lergies. Clinical examination revealed no neurological deficit, in particular neither dysmetria nor motor or sensitive deficit, and the patient’s physical examination was normal except for a right beating horizontal nystagmus in primary position. Due to vomiting and overt vagal signs, upright position was impossible to evaluate. The blood pressure was found high and symmetric in both arms (160/100 mmHg), but the other vital signs were normal (HR 80 beats/min, SpO 2 99% in FiO 2 21%, temperature 36.5°C). The National Institutes of Health Stroke Scale (NIHSS) was 0 [1]. The absence of otological and aural symptoms, as well as the absence of a recurrent vertigo in the history of the patient, was not compatible with Menière disease. A vestibular migraine could be excluded too because of the lack of diagnostic criteria of migraine [2]. The patient was free from neurological signs except for nystagmus and referred imbalance. These features could be typical of an acute vestibu- lar syndrome of peripheral origin; however, a more detailed nystagmus evaluation was needed. The STANDING, a recently developed diagnostic algorithm for the evaluation of patients with acute vertigo, was used to evaluate the patient [3] (Fig. 1). Frenzel goggles confirmed the presence of a spontaneous, i.e., not triggered by head movements, horizontal, right beating, and unidirectional nystagmus, thus excluding a benign parox- ysmal positional vertigo (BPPV). As indicated by the diagnostic algorithm, to differentiate a peripheral from a central disease, a head impulse test (HIT) was performed [4]. The HIT test was negative, strongly suggesting a central origin. Therefore, a first- level bedside eco-color Doppler of the neck vessels was obtained that showed the absence of blood flow in the right vertebral artery. These findings prompted the execution of a CT angiogra- phy of cervical and intracranial vessels that showed a sub occlu- sive stenosis of the right vertebral artery at the onset, probably caused by a spontaneous dissection (Fig. 2). To confirm the diag- nosis, the patient underwent a DWI sequences MRI that clearly revealed a cerebellar stroke (Fig. 3a, b). Systemic thrombolysis was not initiated, because of the delay of presentation to the ED (more than 6 h from the onset of symptoms to ED presentation), and ASA was started. Carlotta Casati (  ) carlotta.casati86@gmail.com 1 Emergency Department, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy 2 Department of Surgical Sciences and Translational Medicine, Unit of Audiology Azienda Ospedaliero-Universitaria Careggi, Florence, Italy Fig. 1: Diagram of STANDING approach. HIT head impulse test, VN vestibular neuritis Acute isolated Vertigo (no other neurological deficits) Nystagmus (Frenzel goggles) Absent Positional SponTAneous HIT Positive VN Suspected Central Vertigo Otolithic disorders Negative Uni Directional  Pluri directional/ Vertical StandiNG (ataxia) Pagnini Horizontal plane Dix–Hallpike Sagittal plane 16  |  Issue-1 MEDICAL EXCELLENCE