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67-year-old woman with episodic vertigo
  1. Roberto Luis Mendes Franco1,2,
  2. Diego Kaski3
  1. 1Department of Neurology, Hospital Central do Funchal – SESARAM, Funchal, Madeira, Portugal
  2. 2Department of Neurology, Centro Hospitalar Universitário de São João, Porto, Portugal
  3. 3Neurosciences, Imperial College London, London, UK
  1. Correspondence to Dr Roberto Luis Mendes Franco, Department of Neurology, Hospital Central do Funchal – SESARAM, Funchal, Madeira, Portugal; robertolfranco{at}gmail.com

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A 67-year-old woman developed sudden imbalance while getting up at night. She collided with the glass shower door and fell into the toilet but without hitting her head. She returned to bed but when on turning over, she had intense rotational vertigo with nausea, which recurred with head movement, but subsided when her head was stationary. She also had transient left-sided facial weakness, sensory loss in the right arm and slurred speech lasting a few minutes, but not present when assessed in the emergency department.

Question 1

What is the most likely initial differential diagnosis?

Comment

When assessing a patient with vertigo, it is the timing and triggers of symptoms rather than just their nature that helps distinguish between different vestibular syndromes, and each has a specific treatment strategy.1 2

There are two common diagnostic scenarios: an acute vestibular syndrome, with prolonged dizziness or vertigo over 24 hours, nausea, vomiting and balance issues, and an episodic vestibular syndrome, manifesting spontaneously or triggered by movement.3

It is essential to identify whether an acute vestibular syndrome has a central (potentially sinister) or peripheral origin (more common and less urgent). Vestibular neuritis is a common cause of a peripheral acute vestibular syndrome and is characterised by spontaneous onset of symptoms,2 unlike this patient’s symptoms where vertigo was seemingly provoked by head movement.

Additionally, she had acute, transient symptoms including left-sided facial weakness, sensory loss in the right arm and slurred speech, raising the possibility of a posterior circulation transient ischaemic attack (TIA).

A transient ischaemic lesion involving the lateral portion of the caudal pons, including the short and long vertebrobasilar branches, could explain left-sided facial weakness (facial nerve), sensory loss in the right arm (spinothalamic tract) and slurred speech (corticobulbar pathways).

Additionally, transient occlusion of the left posterior inferior cerebellar artery …

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Footnotes

  • Contributors RMF contributed to acquisition, analysis and interpretation of the data, drafting of the manuscript and critical revision of the manuscript for intellectual content. DK contributed to acquisition, analysis and interpretation of the data, study supervision, concept and design, and critical revision of the manuscript for intellectual content.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally reviewed by Michael Halmagyi, Sydney, Australia.