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Early MRI-negative posterior circulation stroke presenting as acute dizziness

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Abstract

The aim of this study was to determine the frequency, clinical and radiological features, and efficacy of clinical evaluation and perfusion-weighted imaging (PWI) for the prediction of final stroke in patients with DWI/MRI-negative posterior circulation stroke (PCS) presenting acute dizziness/vertigo. From our comprehensive prospective stroke registry of acute ischemic stroke during a 7-year period, we identified 1846 consecutive patients with PCS, 850 of whom presented with acute dizziness/vertigo. Of these 850 patients, initial DWI-MRI was negative in 35 (4.1%). In these 35 patients, dizziness/vertigo was acute prolonged in 31 and recurrent transient in 4. Focal neurological signs or profound imbalance were present in 16/35 or 18/34, respectively. Spontaneous nystagmus was absent in 21/35; the HINTS protocol (head impulse, nystagmus, and test-of-skew) was not applicable to them. In 12/26 patients, PWI was positive and the same time as DWI was negative. The usual site of lesion was the lateral medulla (n = 18). Twenty-nine patients (83%) had small strokes, while 19 (54%) had large vessel strokes. The sensitivity of systematic clinical evaluation adopting neurological examination, HINTS plus, and assessment of equilibrium was 83%, for prediction of final stroke and 100% when combined with PWI. An integrated approach using systematic neurological and neuro-otological examinations combined with PWI accurately diagnoses PCS presenting with acute dizziness/vertigo. Although most patients with acute vertigo and MRI-negative PCS have small brainstem strokes, about a half have large vessel stroke with greater risk of progression requiring prompt treatment.

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References

  1. Choi KD, Kim JS (2018) Vascular vertigo: updates. J Neurol Sep 5:1–9 [Epub ahead of print]

    Google Scholar 

  2. Arch AE, Weisman DC, Coca S, Nystrom KV, Wira CR, Schindler JL (2016) Missed ischemic stroke diagnosis in the emergency department by emergency medicine and neurology services. Stroke 47:668–673

    Article  Google Scholar 

  3. Tao WD, Liu M, Fisher M, Hao ZL, Lin S, Zhang CF, Zeng QT, Wu B (2012) Posterior versus anterior circulation infarction: how different are the neurological deficits? Stroke 43:2060–2065

    Article  Google Scholar 

  4. Tarnutzer AA, Lee SH, Robinson KA, Wang Z, Edlow JA, Newman-Toker DE (2017) ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: a meta-analysis. Neurology 88:1468–1477

    Article  Google Scholar 

  5. Caplan LR (2007) Dizziness: how do patients describe dizziness and how do emergency physicians use these descriptions for diagnosis? Mayo Clin Proc 82:1313–1315

    Article  Google Scholar 

  6. Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE (2009) HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke 40:3504–3510

    Article  Google Scholar 

  7. Kerber KA, Newman-Toker DE (2015) Misdiagnosing Dizzy patients: common pitfalls in clinical practice. Neurol Clin 33:565–575

    Article  Google Scholar 

  8. Kerber KA, Zahuranec DB, Brown DL, Meurer WJ, Burke JF, Smith MA, Lisabeth LD, Fendrick AM, McLaughlin T, Morgenstern LB (2014) Stroke risk after nonstroke emergency department dizziness presentations: a population-based cohort study. Ann Neurol 75:899–907

    Article  Google Scholar 

  9. Atzema CL, Grewal K, Lu H, Kapral MK, Kulkarni G, Austin PC (2016) Outcomes among patients discharged from the emergency department with a diagnosis of peripheral vertigo. Ann Neurol 79:32–41

    Article  Google Scholar 

  10. Newman-Toker DE (2016) Missed stroke in acute vertigo and dizziness: it is time for action, not debate. Ann Neurol 79:27–31

    Article  Google Scholar 

  11. Saber Tehrani AS, Kattah JC, Kerber KA, Gold DR, Zee DS, Urrutia VC, Newman-Toker DE (2018) Diagnosing stroke in acute dizziness and vertigo: pitfalls and pearls. Stroke 49:788–795

    Article  Google Scholar 

  12. Saber Tehrani AS, Kattah JC, Mantokoudis G, Pula JH, Nair D, Blitz A, Ying S, Hanley DF, Zee DS, Newman-Toker DE (2014) Small strokes causing severe vertigo: frequency of false-negative MRIs and nonlacunar mechanisms. Neurology 83:169–173

    Article  Google Scholar 

  13. Bulut HT, Yildirim A, Ekmekci B, Eskut N, Gunbey HP (2014) False-negative diffusion-weighted imaging in acute stroke and its frequency in anterior and posterior circulation ischemia. J Comput Assist Tomogr 38:627–633

    Article  Google Scholar 

  14. Oppenheim C, Stanescu R, Dormont D, Crozier S, Marro B, Samson Y, Rancurel G, Marsault C (2000) False-negative diffusion-weighted MR findings in acute ischemic stroke. Am J Neuroradiol 21:1434–1440

    CAS  PubMed  Google Scholar 

  15. Sylaja PN, Coutts SB, Krol A, Hill MD, Demchuk AM, VISION Study Group (2008) When to expect negative diffusion-weighted images in stroke and transient ischemic attack. Stroke 39:1898–1900

    Article  CAS  Google Scholar 

  16. Zuo L, Zhang Y, Xu X, Li Y, Bao H, Hao J, Wang X, Li G (2015) A retrospective analysis of negative diffusion-weighted image results in patients with acute cerebral infarction. Sci Rep 5:8910

    Article  CAS  Google Scholar 

  17. Chalela JA, Kidwell CS, Nentwich LM, Luby M, Butman JA, Demchuk AM, Hill MD, Patronas N, Latour L, Warach S (2007) Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison. Lancet 369:293–298

    Article  Google Scholar 

  18. van Rooij FG, Vermeer SE, Góraj BM, Koudstaal PJ, Richard E, de Leeuw FE, van Dijk EJ (2015) Diffusion-weighted imaging in transient neurological attacks. Ann Neurol 78:1005–1010

    Article  Google Scholar 

  19. Tatu L, Moulin T, Bogousslavsky J, Duvernoy H (1996) Arterial territories of human brain: brainstem and cerebellum. Neurology 47:1125–1135

    Article  CAS  Google Scholar 

  20. Choi JH, Kim HW, Choi KD, Kim MJ, Choi YR, Cho HJ, Sung SM, Kim HJ, Kim JS, Jung DS (2014) Isolated vestibular syndrome in posterior circulation stroke: Frequency and involved structures. Neurol Clin Pract 4:410–418

    Article  Google Scholar 

  21. Edlow JA, Gurley KL, Newman-Toker DE (2018) A new diagnostic approach to the adult patient with acute dizziness. J Emerg Med 54:469–483

    Article  Google Scholar 

  22. Kerber KA, Meurer WJ, Brown DL, Burke JF, Hofer TP, Tsodikov A, Hoeffner EG, Fendrick AM, Adelman EE, Morgenstern LB (2015) Stroke risk stratification in acute dizziness presentations: a prospective imaging-based study. Neurology 85:1869–1878

    Article  Google Scholar 

  23. Chen L, Lee W, Chambers BR, Dewey HM (2011) Diagnostic accuracy of acute vestibular syndrome at the bedside in a stroke unit. J Neurol 258:855–861

    Article  CAS  Google Scholar 

  24. Mlynash M, Olivot JM, Tong DC, Lansberg MG, Eyngorn I, Kemp S, Moseley ME, Albers GW (2009) Yield of combined perfusion and diffusion MR imaging in hemispheric TIA. Neurology 72:1127–1133

    Article  CAS  Google Scholar 

  25. Lee J, Inoue M, Mlynash M, Mann SK, Cereda CW, Ke M, Albers GW, Olivot JM (2017) MR perfusion lesions after TIA or minor stroke are associated with new infarction at 7 days. Neurology 88:2254–2259

    Article  Google Scholar 

  26. Grams RW, Kidwell CS, Doshi AH, Drake K, Becker J, Coull BM, Nael K (2016) Tissue-negative transient ischemic attack: is there a role for perfusion MRI? Am J Roentgenol 207:157–162

    Article  Google Scholar 

  27. Choi JH, Park MG, Choi SY, Park KP, Baik SK, Kim JS, Choi KD (2017) Acute transient vestibular syndrome: prevalence of stroke and efficacy of bedside evaluation. Stroke 48:556–562

    Article  Google Scholar 

  28. Kim DU, Han MK, Kim JS (2011) Isolated recurrent vertigo from stenotic posterior inferior cerebellar artery. Otol Neurotol 32:180–182

    Article  Google Scholar 

  29. Xu X, Jiang L, Luo M, Li J, Li W, Sheng W (2015) Perfusion-weighted magnetic resonance imaging detects recurrent isolated vertigo caused by cerebral hypoperfusion. Int J Neurosci 125:449–455

    Article  Google Scholar 

  30. Tarnutzer AA, Berkowitz AL, Robinson KA, Hsieh YH, Newman-Toker DE (2011) Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome. CMAJ 183:E571–E592

    Article  Google Scholar 

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Acknowledgements

The authors would like to thank Dr. GM Halmagyi for his linguistic correction and comprehensive comments on our manuscript.

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Correspondence to Kwang-Dong Choi.

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All authors declare that they have no conflict of interest.

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This study followed the tenets of Declaration of Helsinki and was approved by Institutional Review Board of Pusan National University and Pusan National University Yangsan Hospitals. Informed contents were obtained after the nature and possible consequence of this study had been explained to the participants.

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Choi, JH., Oh, E.H., Park, MG. et al. Early MRI-negative posterior circulation stroke presenting as acute dizziness. J Neurol 265, 2993–3000 (2018). https://doi.org/10.1007/s00415-018-9097-z

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