Up to 10% of patients with cerebellar infarctions will present with vertigo and no other focal neurologic deficits. Not all patients, however, present with these symptoms. These symptoms include vertigo, ipsilateral facial numbness, loss of corneal reflex, Horner’s syndrome (i.e., ipsilateral miosis, ptosis and anhidrosis), pharyngeal and laryngeal paralysis, and contralateral loss of pain and temperature sensation in the extremities. A large infarction of the PICA classically causes symptoms of lateral medullary syndrome (i.e., Wallenberg syndrome). The other two branches are the anterior inferior cerebellar artery (AICA) as well as the superior cerebellar artery (SCA). The posterior inferior cerebellar artery (PICA) is a branch of the vertebral artery and one of three supplying arteries to the cerebellum. 3 It is therefore crucial to differentiate between central and peripheral vertigo as certain causes of central vertigo can be fatal when left untreated. Central causes are generally more serious and include vascular disorders such as cerebellar masses, hemorrhage and infarction. Other characteristics of central vertigo include nystagmus in any direction, symptoms not exacerbated by body position, and the presence of neurologic findings. It may also present as sudden and severe in nature, lasting seconds to minutes. 3Ĭentral vertigo can present gradually and mild in intensity and continue for weeks to months. Peripheral etiologies include benign paroxysmal positional vertigo, labyrinthitis, Meniere’s disease, vestibular neuritis, and acoustic neuroma. Peripheral vertigo generally lacks neurologic findings, although there may be tinnitus (i.e., perception of ringing in ears) or decreased hearing. In this type of vertigo, nystagmus is classically horizontal with symptoms exacerbated by head position. 2 Peripheral vertigo is generally characterized by sudden onset and severe intensity which last seconds to minutes. 2 Clinicians can evaluate symptom onset, intensity, duration, direction of nystagmus (i.e., involuntary eye movement), associated neurologic findings and auditory findings as well as positional effect. 1 A first step in evaluating a patient with vertigo is distinguishing between central and peripheral etiologies. Vertigo has been defined as a pathologic illusion of movement. Vertigo is a common complaint in patients presenting to the emergency department, as well as other outpatient settings. Implementing this strategy may decrease morbidity and mortality associated with cerebellar infarctions. When differentiating benign forms of vertigo from cerebellar infarcts or other central causes, the clinician should take into account risk factors such as central symptoms including neurologic deficits and severe ataxia. Imaging subsequently revealed the patient to have sustained a cerebellar infarct. On initial exam, he had no focal neurologic deficits but did have other concerning symptoms including severe ataxia. The following case report discusses a male in his late twenties with the chief complaint of vertigo. Up to 10% of patients with cerebellar infarctions, however, present to the emergency department with vertigo and no focal neurologic deficits. Classic signs of a cerebellar infarct include symptoms suggestive of central vertigo with focal neurologic deficits on physical exam. Although ruling out these types of fatal diagnoses is essential for emergency medicine physicians, this task can be especially complicated. Although most patients with vertigo, especially younger patients, will have a benign disorder, up to 3% of such patients will have a cerebellar infarct. It can be a manifestation originating from several different disease processes. Vertigo is a common complaint in patients who present to the emergency department.
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