Case Report : 1

Vertigo and Diplopia in an Epilepsy Man

History : This 82 year-old right-handed male was driving his car when he suddenly became aware of a spinning sensation and feeling as though he were "drunk". He pulled the car over to the side to the side of the road, and after a few minutes, he again was asymptomatic. A few hours later, he noted side by side double vision which cleared when either eye was closed. He began to experience a rotary or whirling sensation with rapid position change. Two days later he consulted you.

Questions :

1. This symptomatology suggests neurologic dysfunction in which of the following areas?
A. Cerebral cortex
B. Visual pathways
C. Brain Stem
D. Cerebellar system.

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2. The sudden onset of Neurologic Dysfunction at this age is most suggestive of :
A. Vascular disease
B. Diabetes mellitus
C. Central nervous system neoplasm
D. A demyelinating disorder, such as late onset MS.

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Further history revealed that six months prior to the onset of these neurologic symptoms, he became aware of intermittent claudication. He has had no known cardiac disease, hypertension, or diabetes mellitus. About five years ago, he had two episodes of spontaneous epistaxis a few days apart, but otherwise, there has been no evidence of blood dyscrasia. Eight years ago, he had a subtotal gastrectomy for peptic ulcer disease, and since then has been asymptomatic.

The family history reveals that his mother died during the influenza epidemic in 1917. She had diabetes late in life. One sister also possibly is a diabetic. His father died at age 42 trauma. Two siblings have a history of heart disease.

Physical examination reveals an alert, well-nourished gentleman, who appeared considerably younger than his stated age. Blood pressure 195/80, both arms, sitting. The dorsalis pedis and posterior tibial pulses were absent bilaterally. The carotid pulsations were strong bilaterally. There was a Grade II systolic bruit in the left supraclavicular area. No intracranial bruit was present. There was no evidence of impairment of mentation. On gait testing there was unsteadiness and swaying with rapid turns and difficulty performing tandem walking. There was slight slowing of left foot tapping. The pupils were 2mm bilaterally and reacted normally.

There were minimal atherosclerotic changes in the retinal vessels, and no appilledema was present. There was diplopia on left lateral gaze and to a greater extent on right lateral gaze. The images were horizontally displayed. With extreme right lateral gaze, there was unilateral nystagmus of the right eye with impairment of full medial gaze in the left eye. There was a suggestive, but not definite, left lateral rectus palsy. The rest of the cranial nerves were normal.

Sensory examination was intact to superficial, deep and discriminative modalities. Motor examination revealed no paresis or cerebellar deficit, and the reflexes were equal and active bilaterally with no abnormal reflexes present.

Questions :

3. The Abnormalities of ocular motility can best be ascribed to :
A. A conversion reaction
B. Drug effect
C. Interruption of the median longitudinal fasciculus
D. Involvement of the dentate nucleus of the cerebellum

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4. Which of the following statements are true?
A. A bruit over an extracranial vessel in the neck always indicate stenosis of the artery being ausculated
B. Because of flow patterns, a bruit may be present over the unobstructed side
C. Significant stenosis may be present without a bruit
D. All systolic bruits over the carotid arteries are pathological and require further investigation.

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Course : This patient was hospitalized, and was found to have normal skull films, an unremarkable electroencephalogram and brain scan and normal spinal fluid. He was mildly diabetic, and was placed on a diabetic diet. A surgical consultation was obtained. The vascular surgeon felt that consideration of surgical repair was not indicated because of the patient's age, and the fact that his disease most likely was in the basilar-vertebral distribution. Because of his history of peptic ulcer disease, epistaxis and absence of clinical evidence that his stroke was progressive or recurrent, it was elected not to give his anticoagulation. Over the next four months, his clinical signs gradually improved, although he continued to experience mild diplopia on extreme right lateral gaze.

Questions :

5. Which of the following situations calls for anticoagulation?
A. Transient insufficiency attacks
B. Stroke-in-evolution
C. Completed stroke
D. Recurrent cerebral emboli

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6. Which of the following signs may be seen in vertebral basilar occlusive disease?
A. Nystagmus
B. Horner's syndrome
C. Bilateral Babinski's
D. Hemiparesis
E. All of the above

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True or False :

7. Chronic use of vasodilators is frequently indicated in atherosclerotic cerebrovascular disease.

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8. Vasodilators may be indicated in the initial management of the stroke patient.

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9. Seizures are common in basilar artery disease

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10. The basilar-vertebral distribution is a common site for cerebral emboli from rheumatic heart disease.

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11. Lumbar puncture is indicated in most patients with stroke.

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12. Which of the following may precipitate a transient insufficiency attack in a patient with underlying arterial disease?
A. Orthostatic hypotension
B. Cardiac arrhythmia
C. Embolic plaque from atherosclerotic lesion
D. Hypercoagulable state
E. All of the above.

Ans

Answers and Discussions :

1. C The phenomenon of diplopia indicates a loss of normal conjugate eye movements. This is usually due to a lesion of the brain stem or one of the nerve innervating the eye muscles. In myasthenia gravis, diplopia can occur with the defect at the neuromuscular junction.

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2. A Neurologic deficit that begins suddenly, if it is not a seizure disorder, is usually either vascular in origin or a manifestation of a demyelinating process such as multiple sclerosis. In demyelinating disease, the onset of neurologic deficit is rarely lightening-like, but rather evolves over a period of several hours at the least. Vascular disease, regardless of the kind of circulatory disorders, characteristically begins abruptly. This is true regardless of whether the underlying mechanism is embolism, hemorrhage, or ischemic thrombosis. Since demyelinating disease, especially those that are rapid on onset, involve primarily younger individuals, the sudden onset of neurologic deficit in an adult almost always indicates a disorder of blood supply of some variety.

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3. C Nystagmus of the abducting eye on attempted lateral gaze with limitation of movement of the adducting eye is termed internuclear ophthalmoplegia and is caused by a lesion of the median logitudinal fasciculus in the brain stem.

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4. C Physiologic bruits are fairly common, especially in young males where they appear are rather localized systolic bruits at the base of the right carotid. This bruit increases with heart rate and can be altered with position. Pathologic bruit usually does not change significantly with alteration of heart rate or position. If a vessel is completely occluded, a bruit will not be present over that vessel, but may be heard over the contralateral vessel as flow in this channel shows a compensatory increase.

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5.ABD There is general agreement that 1) if the patient's clinical syndrome is one of transient insufficiency attacks, 2) if the diagnosis is reasonably certain, 3) if other correctable factors have been treated, and 4) if no contraindication is present, that anticoagulation will decrease the number of insufficiency attacks is most patients, and in some will stop them completely. It is not entirely clear, however, that anticoagulation in the patient with TIA's results in a decreased incidence of eventual cerebral infarction.

There is lesser agreement over the use of anticoagulation in the stroke-in-evolution syndrome and in recurrent cerebral emboli. Because of the not insignificant incidence of anticoagulation induced intracerebral hemorrhage, many have been reluctant to use anticoagulation in these two situations. Other evidence, however, indicates that on balance the patient will benefit from immediate anticoagulation. The evidence and clinical opinion is therefore divided in these two situations. Most authorities, however, tend to favor immediate anticoagulation in both situations. In the "completed stroke" syndrome there is general agreement that chronic anticoagulation does not prevent the recurrence of further cerebral infarctions and is therefore not indicated.

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6. E The major supply of the vertebral-basilar system is the brain stem and the occipital lobes. Thus, with either vertebral-basilar insufficiency or complete occlusion, one finds variable symptoms and signs referable to brain stem dysfunction: Cerebellar signs may also occur. Nystagmus, hemiparesis and bilateral Babinski's are very common. Horner's syndrome may occur if the appropriate pathways in the brain stem are interrupted. Hypothalamic dysfunction as manifested by wide fluctuations in blood pressure and temperature may occur. "Crossed" motor and sensory syndromes may be found.

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7. False
8. True
9. False
10.False

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11.True There is general agreement that chronic use of vasodilators is not of significant
benefit in the patient with the usual variety of atherosclerotic cerebrovascular disease. In some patients, vasodilators may induce orthostatic hypotension which can be deleterious. In the initial phase of a vascular occlusion, however, several authors favor the use of vasodilators, especially papaverine hydrochloride. This has been debated in literature, however, sincere there is evidence that in certain situations vasodilation may shunt blood from an ischemic area. Seizures as a manifestation of cerebrovascular disease occur primarily with cerebral embolus and intracerebral hemorrhage. Although they do occur, they are very infrequent in the acute stage of a cerebral thrombosis. They are extremely uncommon in any form of basilar artery disease. The basilar-vertebral distribution is also a very uncommon site for a cerebral embolus regardless of its origin or etiology. In most patients who have sustained a stroke, a lumbar puncture is indicated. This is primarily to rule out subarachnoid or intracerebral hemorrhage.

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12. E The phenomenon of transient cerebral insufficiency attacks has received considerable interest and study over the past several years. At the present time, it would appear that many mechanisms are involved in precipitating such an event. In any one individual, these factors may be multiple and careful evaluation of each possibility is indicated. In some patients the episodes are clearly associated with mechanisms that cause orthostatic hypotension, such as urinating after arising from sleep. Occasionally, Strokes-Adams attacks and other cardiac dysrhythmias may present primarily as a TIA. It has been clearly documented that emboli may arise from an atherosclerotic lesion in the more proximal vascular bed. These emboli may consist of small thrombi or cholesterol crystals. TIA's also occur in the setting of hyperlipidemia, increased platelet adhesiveness, and other situations that result in a hypercoagulable state. The mechanism of vasospasm has been debated at great lengths and it is still unclear whether this is a significant factor in producing TIA's. Anemia and electrolyte disturbances may also be contributory.

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