Case Presentation: A previously healthy 37-year-old male presented to the Emergency Department (ED) with sudden onset nausea and dizziness that after he had turned and looked over his right shoulder. He experienced 3 episodes of emesis. Emergency Medical Services (EMS) were called due to his severe dizziness. Admit vitals were significant for a heart rate of 40 beats per minute; all other vital signs were normal. In the ED an ECG was performed and read as abnormal with T-wave inversions. A routine head CT did not demonstrate hemorrhage or mass effect. Bedside echocardiogram was performed and, as the patient turned his head to the right, he again experienced severe dizziness. He was admitted for observation. Exam by the admitting physician demonstrated that a Dix-Hallpike maneuver to the right reproduced symptoms of dizziness without nystagmus. He was discharged the following day with tentative diagnosis of benign paroxysmal positional vertigo. His ECG changes were attributed to juvenile T-wave pattern. His bradycardia demonstrated chronotropic competence when stressed and was attributed to his overall physical fitness. He followed up with his primary care doctor and was referred to otolaryngology and physical therapy for persistent symptoms of dizziness. Over three weeks he experienced persistent episodes of episodic dizziness. During one episode of vestibular physical therapy the patient’s symptoms acutely worsened. An MRI was performed and was significant for numerous right cerebellar lacunar infarcts. A CT angiogram was performed, demonstrating left vertebral artery dissection.
Discussion: Vertebral artery dissection (VAD) is one of the most common causes of stroke in patients under the age of 45. Patients with VAD can present with relatively non-specific complaints, such as dizziness, headache, neck pain, and nausea/vomiting. Unfortunately, without adequate physical exam and clinical suspicion, many VAD related strokes are missed. This is likely due to the fact that posterior strokes can present as acute vestibular syndrome (AVS), which is rapid onset vertigo accompanied by nausea/vomiting, unsteady gait, and nystagmus. AVS is most frequently a problem of the peripheral vestibular system, i.e. neuritis vs labyrinthitis. However, AVS can also be caused by central lesions, specifically those in the brain stem or cerebellum.
We suspect that this patient’s symptoms of vertigo with head turning resulted from a form of Bow Hunter’s Syndrome, whereby rotation of the neck caused further occlusion of the dissected vessel and resulted in basilar insufficiency. The timing of his strokes is unclear; however it is likely that each of his presentations, the sentinel presentation to the ED and the final presentation for diagnosis, represented separate strokes.
This patient’s dissection and subsequent strokes might have been detected earlier with more thorough physical exam. The Dix-Hallpike test, performed on this patient, does not provide sufficient evidence to differentiate central from peripheral causes of vertigo. A superior exam, which is more sensitive for stroke, is the HINTS exam, which is an acronym for Head-Impulse, Nystagmus, Test of Skew. Had this exam been performed on our patient, his disease might have been discovered sooner.
Conclusions: VAD is an uncommon but important cause of vertigo. Central causes of vertigo are difficult to distinguish from peripheral causes. Broader education on the HINTS exam rather than the Dix-Hallpike exam may help to better identify patients with central causes of vertigo.