Management of Stroke Associated with Ongoing Vertigo

Diagnostic Approach

The American College of Radiology recommends distinguishing between peripheral and central causes of vertigo, as stroke is a dangerous cause of acute vestibular syndrome that requires immediate intervention, with a prevalence of cerebrovascular disease in patients presenting with AVS being approximately 25% and may be as high as 75% in high vascular risk cohorts 1
Focal neurologic symptoms/signs may be lacking in one-third to two-thirds of patients with stroke-related vertigo, highlighting the importance of a thorough diagnostic approach 1
The HINTS examination should be performed to distinguish between peripheral and central vertigo, with a sensitivity of 100% for detecting stroke when performed by specially trained practitioners, compared to 46% for early MRI 1
Nystagmus patterns suggesting central cause, such as downbeating nystagmus, direction-changing nystagmus without head position changes, gaze-holding nystagmus, or baseline nystagmus without provocative maneuvers, can indicate stroke 2
Failure to respond to standard vestibular treatments can also suggest stroke 2

The American Academy of Otolaryngology-Head and Neck Surgery suggests assessing patients for factors that modify management, including impaired mobility or balance, CNS disorders, lack of home support, and increased risk for falling, with elderly patients having a 12-fold increase in the risk for falls 2
Falls risk screening should be performed, particularly in elderly patients, to prevent falls and related complications 2

The American College of Radiology advises against relying solely on CT imaging, as it frequently misses posterior circulation strokes, and assuming absence of focal neurologic deficits rules out stroke, as up to 80% of patients with stroke-related AVS may have no associated focal neurologic deficits 1