Medical Excellence - Issue 2

Isolated Transient Vertigo: Posterior Circulation Ischemia or Benign Origin? Tobias F. Blasberg 1 *, LeaWolf 1 , Christian Henke 1,2 , Matthias W. Lorenz 1,3 Background Vertigo is a frequent reason for emergency presentation [1–5] with manifold causes [3, 4, 6–8]. If focal neurological signs or symptoms occur, transient ischemic attack (TIA) may be di- agnosed; otherwise cerebral ischemia seems unlikely [6–8]. In unselected samples, (proven) cerebrovascular cause in isolated vertigo is rare [9] and risk for future stroke is low [10], however higher than in other emergency patients [11], in particular when vascular risk factors (VRFs) are present [11]. In the last decade, increasing evidence has been put forward to show that posterior circulation ischemia can present with isolated vertigo without focal signs [9, 12]. Even more disconcerting are findings from the OxVasc study: 22% of posterior circulation stroke patients reported subtle transient neurological symptoms in the 90 days preceding their stroke, most frequently vertigo [13]. To preclude future strokes it is crucial to identify those patients whose vertigo episode was a subtle TIA. For the clinician, there are two typical situations: the patient with acute onset, ongoing vertigo, and the patient free of symp- toms on presentation, who reports (often multiple) transient *Correspondence: Tobias.Blasberg@stud.uni-frankfurt.de 1 Department of Neurology, Frankfurt University Hospital, Schleusenweg 2-16, 60528 Frankfurt am Main, Germany 2 Department of Neurology, Helios HSK Wiesbaden, Ludwig-Erhard-Straße 100, 65199 Wiesbaden, Germany 3 Department of Neurology, Krankenhaus Nordwest, Steinbacher Hohl 2-16, 60488 Frankfurt/Main, Germany Background: Isolated transient vertigo can be the only symptom of posterior circulation ischemia. Thus, it is important to differentiate isolated vertigo of a cerebrovascular origin from that of more benign origins, as patients with cerebral ischemia have a much higher risk for future stroke than do those with‘peripheral’vertigo. The current study aims to identify risk factors for cerebrovascular origin of isolated transient vertigo, and for future cerebrovascular events. Methods: From the files of 339 outpatients with isolated transient vertigo we extracted history, clinical and technical find- ings, diagnosis, and follow-up information on subsequent stroke or transient ischemic attack (TIA). Risk factors were analyzed using multivariate regression models (logistic or Cox) and reconfirmed in univariate analyses. Results: On first presentation, 48 (14.2%) patients received the diagnosis ‘probable or definite cerebrovascular vertigo’. During follow-up, 41 patients suffered stroke or TIA (event rate 7.9 per 100 person years, 95% confidence interval [CI] 5.5–10.4), 26 in the posterior circulation (event rate 4.8 per 100 person years, 95% CI 3.0–6.7). The diagnosis was not as- sociated with follow-up cerebrovascular events. In multivariate models testing multiple potential determinants, only the presentation mode was consistently associated with the diagnosis and stroke risk: patients who presented because of vertigo (rather than reporting vertigo when they presented for other reasons) had a significantly higher risk for future stroke or TIA ( p = 0.028, event rate 13.4 vs. 5.4 per 100 person years) and for future posterior circulation stroke or TIA ( p = 0.044, event rate 7.8 vs. 3.5 per 100 person years). Conclusions: We here report for the first time follow-up stroke rates in patients with transient isolated vertigo. In such pa- tients, the identification of those with cerebrovascular origin remains difficult, and presentation mode was found to be the only consistent risk factor. Confirmation in an independent prospective sample is needed. Keywords: Cerebrovascular, Stroke, Transient, Transient ischemic attack, Vertigo Issue-2  |  13 MEDICAL EXCELLENCE