Small strokes causing severe vertigo. Frequency of false negative MRI's and

nonlacunar mechanisms.

 

Tehrani ASS, Kattah JC, Mantokoudis G, et al. Neurololgy 2014; 83: 169=173

 

Introduction

Out of acute vestibular syndrome (AVS)  25 % have stroke

80 % of patients with stroke have isolated dizziness/vertigo and 20 % have focal neurologic signs

35 % of strokes are missed, often with negative MRI's. 

 

Results

Out of 190 high risk  AVS presentations, 105 strokes

15  "small strokes" who underwent repeat imaging and found lesion < 10 mm in axial diameter

 

Location of stroke: lateral medulla (60 %)

Etiology Many dissections of vertebral artery, less commonly small vessel, cardiac embolus 

 

"HINTS PLUS" with the plus being a "hearing battery" bedside finger rub picks up the AICA strokes more accurately than MRI

 

My comment-

Lateral medullary infarctions have expected neurologic signs and symptoms that may be missed by physicians who do not know what to look for.  These include decreased gag/phonation, and crossed sensory symptoms (loss of st tract on one foot, dorsal column function on the other) that will pick up many or most of those. I would guess that in AVS with HINTS plus hearing eval plus careful gag/sensory exam some if not most of the strokes could be diagnosed clinically and localized accurately.  MRI is a poor test in this disease, but diagnosis is possible.

 

DJ