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My Heart is Racing! Select Cardiac Arrhythmias and Practice Updates

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viernes, 17 de marzo de 2017

Posterior Circulation Strokes

emDocs
emDocs - March 15, 2017 - Authors: Pawlukiewicz A and Long D
Edited by: Koyfman A and Long B
"Pearls and Pitfalls
Pearls
  • Clarify what the patient means by dizziness regarding timing and triggers of the onset of symptoms. Distinguish dizziness from syncope or other mimicking conditions, as these will require a different work-up.
  • Suspect a central etiology in patients with acute vestibular syndrome. Evaluate with the HINTS exam.
  • Use the HINTS test in patients presenting with Acute Vestibular Syndrome, as this is more sensitive than both CT and MRI for posterior circulation strokes.
  • Nystagmus is assessed during lateral gaze at 45-60 degrees, not at end-gaze. An abnormal response in a patient with AVS is vertical or torsional nystagmus. 
  • The HINTS exam should only be used in patients presenting with Acute Vestibular Syndrome, not patients with Triggered or Spontaneous Episodic Vertigo Syndrome.
Pitfalls
  • Symptoms that worsen with movement do not confirm a peripheral process. Symptoms with movement may also exacerbate symptoms from a central process.
  • A normal head CT is not sufficient in excluding ischemic stroke.
  • MRI should not be relied upon in the initial 24-48 hours after symptom onset to rule out a posterior circulation stroke, as it may miss up to 10-20% of posterior circulation strokes.
  • Younger age does not exclude central causes of Acute Vestibular Syndrome. A stroke should still be suspected in patients younger than 50 if the physical exam is concerning for a central process.
  • Many of the classic distinguishing features of peripheral lesions are also found in central lesions."