Medical Excellence- Issue 1

The patient was admitted to the neurologic ward. The next day the patient’s neurologic state worsened, and a new onset dysmetria of the left arm, left hemi-anaesthesia of the face, left VI and VII cranial nerves palsy, and left hearing loss were de- tected. The patient underwent new MRI, and acute lesions in the left cerebellar peduncle were found. An anticoagulant therapy with low molecular heparin was started instead of antiplatelet agents, and after 3 days, it was switched to an oral anticoagu- lants therapy. The patient underwent rehabilitation program, and when he was discharged, he was able to stand and walk with aid, the left dysmetria improved, while the VI cranial nerve palsy, the left hemi-anaesthesia of the face, and the left hearing loss, as the nystagmus, were still present. Compliance with ethical standards Conflict of interest  None. Statement of human and animal rights  All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent  Informed consent was obtained from all individual par- ticipants included in the study. References 1. Brott T, Adams HP Jr, Olinger CP, Marler JR, Barsan WG, Biller J, Spilker J, Holleran R, Eberle R, Hertzberg V et al (1989) Measure- ments of acute cerebral infarction: a clinical examination scale. Stroke 20:864–870. 2. Headache Classification Committee of the International Headache Society (IHS) (2013) The International Classification of Headache Disorders, 3rd edition (beta version. Cephalalgia 33(9):629–808. 3. Vanni S, Pecci R, Casati C, Moroni F, Risso M, Ottaviani M, Nazerian P, Grifoni S, Vannucchi P (2014) STANDING, a four-step bedside algo- rithm for differential diagnosis of acute vertigo in the Emergency Department. Acta Otorhinolaryngol Ital 34(6):419–426. 4. Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE (2009) HINTS to diagnose stroke in the acute vestibular syndrome: three- step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke 40:3504–3510. Source: CarlottaCasati, MatteoCastelli, Andrea Pavellini, CosimoCaviglioli, Rudi Pecci. An Unusual Case of Vertigo: The Usefulness of Nystagmus Examination. Intern Emerg Med . 2016;11(8):1131. DOI 10.1007/s11739- 016-1538-z. © SIMI 2016. Fig. 2: CT angiography of cervical and intracranial vessels showing a sub occlusive stenosis of the right vertebral artery ( white arrow ) at the origin. Fig. 3: ( a ) Brain DWI-MR showing a right cerebellar ischaemic lesion in the PICA territory ( white arrow ). ( b ) Brain T2 sequences MRI showing the same lesion. anticoagulant therapy with low molecular heparin was started instead of antiplatelet agents, and after 3 days, it was switched to an oral anticoagulants therapy. The patient underwent rehabilitation program, and when he was dis- charged, he was able to stand and walk with aid, the left dysmetria improved, while the VI cranial nerve palsy, the left hemi-anaesthesia of the face, and the left hearing loss, as the nystagmus, were still present. Compliance with ethical standards Conflict of interest None. Fig. 1 Diagram of STANDING approach. HIT head impulse test, VN vestibular neuritis Fig. 2 CT angiography of cervic l and intracra sels howing a sub occlusive stenosis of the right verte ral artery ( white arrow ) at the origin Fig. 3 a Brain DWI-MR showing a right cerebellar ischaemic lesion in the PICA territory ( white arrow ). b Brain T2 sequences MRI showing the same lesion 123 anticoagulant therapy with low molecular heparin was started instead of antiplatelet agents, and after 3 days, it was switched to an oral anticoagulants therapy. The patient underwent rehabilitation program, and when he was dis- charged, he was able to stand and walk with aid, the left dysmetria improved, while the VI cranial nerve palsy, the left hemi-anaesthesia of the face, and the left hearing loss, as the nystagmus, were still present. Compliance with ethical standards Conflict of i terest None. Fig. 1 Diagram of STANDING approach. HIT head impulse test, VN vestibular neuritis F g. 2 CT angiography of c rvical and intracranial vessels showing a sub occlusive stenosis of the right vertebral artery ( white arrow ) at the origin Fig. 3 a Brain DWI-MR showing a right c rebe l emic lesion in the PICA territory ( white arrow ). b Brain T2 sequences MRI showing the same lesion 1132 Intern Emerg Med (2016) 11:1131–1133 123 Issue-1  |  17 MEDICAL EXCELLENCE