Cerebellar Infarct Presenting

with Isolated Vertigo

Kam A. Newman, M.D.

Saeed Kahkeshani, M.D.
San Jacinto Methodist Hospital
Baytown, TX
 Case Summary
 The pt is a 54 year old Caucasian female who
found violent vomiting all of sudden and lasted a
couple of days. She was admitted hospital for
profuse vomiting and sever weakness. She denies any
chest pain, SOB, palpitation, vision problem, and
abdominal pain. All lab works were normal except
Lipase 1778, and Amylase 252. Pt discharged with
Diagnosis of probable pancreatitis.
Pt got back to ER with altered mental status, and
persistent vomiting. An MRI of the brain
confirmed subacute cerebellar infarction.
 MRCP
Abrupt tapering of the distal common
bile duct with a distal Short segment of
prominent narrowing.

Top normal hepatic common bile duct

with no filling defects or morphologic
abnormality.
 MRI of the Brain

Diffusion studies demonstrates increased signal

in the posterior portion of both cerebellar
hemispheres consistent with subacute cerebellar
infarction.
 MRI of the Brain (Cont)

ADC mapping demonstrates areas of decreased signal

In both cerebellar hemisphere.
 MRI of the Brain (Cont)

T2 axial consistent with increased signal within the

Both cerebellar hemisphere.
 MRI of the Brain (Cont)

T2 weight FLAIR demonstrates increased signal in both

Both cerebellar hemisphere.
 MRI of the Brain (Cont)

T1 axial shows decreased signal within both cerebellar

Hemispheres.
 Definitions
 Stroke: Sudden death of a portion of the brain
cells due to a lack of oxygen.

 Dizziness (Lightheadedness): A sensation of

altered spatial orientation.

 Vertigo: Any abnormal sensation of motion

between a patient and the surroundings.

 Disequilibrium (Imbalance): Patients may feel

normal when they are stationary, but notice
difficulty when they walk.
 Statistics
 Stroke, after heart disease and cancer, is the third
commonest cause of death in the U.S.

- Killed 150,074 people in 2004.

- About 780.000 people suffer a new or recurrent stroke
each year.

- Almost every 45 seconds in the U.S, a person experiences

stroke.

- Stroke is the leading cause of disability among adults in the

U.S.
 Statistics (Cont)
 Dizziness: No definitive statistics exist about
vertigo/dizziness/imbalance.

- Over 90 million Americans, age 17 and older have

experienced a dizziness or balance problem.

- Dizziness is a common symptom affecting about 30% of

people over the age 65.

- In the general population (all ages), 347.000 hospital days

per year in the U.S. are incurred because of “vertiginous
syndromes”.
 Vertigo, Classification and Causes
 Peripheral: A short or episodic time course, a precipitating
factor, and the presence of autonomic symptoms.

- Benign paroxysmal positional vertigo

- Vestibular Neuritis (VN) - Meniere disease

- Labyrinthine ischemia or hemorrhage/Cholesteatoma

- Acute alcohol intoxication - Ototoxicity/Otosclerosis

- Metabolic Disorders
 Vertigo (Cont)
 Central: Associated neurologic symptoms are diplopia,
hemianopsia, weakness, numbness, dysarthria, ataxia, and
loss of consciousness.

- Vascular disease - Migraine - Seizure disorder

- Cerebellar degeneration syndromes - Multiple sclerosis

- Disorders of the craniovertebral junction

- Neurologic complications of ear infections

 Vestibular Neuritis
 The second most common dizziness diagnosis in
general practice after BPPV.

 Often erroneously called acute or viral labyrintitis.

 By definition, pts with VN have a unilateral

decreased caloric response and the head trust test is
almost always abnormal toward the side of the lesion.
Classification of Stroke
 Symptoms of Stroke

Symptom Ischemic Stroke (%) ICH (%) SAH (%)

Headache 11–17 33–41 78–87

Vomiting 8–11 29–46 45–48

Decreased LOC 13–15 39–57 48–68

Seizure 0.3–3 6–7 7

 Clinical Features
 Headache at onset is an invariable feature of SAH, also
common in patients with large ICHs. Headache is rare in
lacunar infarcts.

 Vomiting is very common in SAH, ICH, and with brain

stem and cerebellar infarcts.

 Seizures at or soon after the stroke are common in patients

with lobar hemmorhages, and brain embolisms, but are
rare in lacunar infarcts.
Cerebellar Infarct and Vertigo
Topographic Distribution of Cerebellar
Infarcts
Vertigo Work up
Thank You & Questions