Not another dizzy A Case Report

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Not another dizzy -A Case Report

• Sudhir Nagaraja DO, MS
• VCUHS Department of Neurology
• April 26, 2007

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Case Presentation
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Chief Complaint and History

• 1st admission 12/12/06
• 61 y/o AAM
• Acute onset dizzyness (sensation of spinning)
• Double vision
• Leaning and falling to the right
• Ongoing for 2 days prior to admit

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Case Report-additional History

• ROS for nausea, vomiting
• ROS for HA, hearing loss, CP, SOB, weakness
• PM Hx HTN, DM (on insulin at home), CAD with
  prior PTCA
• Soc Hx quit smoking 10-15 yrs back

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Case Report-outpatient Meds

• ASA 81mg daily
• Ezetimibe/Simvastatin one tab daily
• HCTZ 25mg daily
• Lisinopril 40mg daily
• Nifedipine ER 90mg daily
• Reg Insulin 125 U AM and HS
• Insulin Aspart 20 U AC evening meal
• Metformin 1000mg BID

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Case Report-initial Gen. Exam

• Vitals-BP 140/66, HR 64, R17, T97
• Normal orthostatic vitals
• Neck-no carotid bruits
• Cardiac-RRR, no murmurs
• Lung-CTA, no R/R/W
• Extremities-no cyanosis, no edema

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Case Report-initial Neuro Exam

• Nystagmus with R gaze, upbeating
• Decreased pain- R face V1-V3
• Intact strength throughout
• Decreased pin, temp, vibration b/l lower
  extremities
• Absent achilles reflexes b/l
• Unable to stand or walk w/o assistance
• When able to walk the next day, ataxic gait,
  falling to the right

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Case Report-laboratory Studies
14.5
220
253
7.0
41.6
Chem panel
Cell count
PT 13.7, PTT 32, INR 1.0 Hemoglobin A1C 8.4, ESR
16, CRP 0.921 LDL 68, cholesterol 120, TG 103,
HDL 31 B12 383, folate 720, MMA 215, HC 10.1
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Differential Diagnosis

• Brainstem ischemia/Infarct
• Demyelinating Disease
• Cerebellopontine angle tumor
• Multiple cranial neuropathies
• Drug Toxicity

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Case Report-Possible Localization
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Discussion of hx and Diagnosis

• Epidemiology
• Pathology
• Imaging
• Management
• Medical
• Interventional
• Outcomes

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Epidemiology Pathology

• About ¼ of ischemic strokes involve posterior or
  vertebro-basilar circulation
• Occurs in twice as many men as women
• Atherosclerosis a major cause of pathology
• HTN DM most important risk factors
• Less common, fibromusc dysplasia, aortoarteritis,
  radiation therapy

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Case Report-imaging Studies

• MRI brain-acute ischemia b/l cerebellar
  hemispheres R lateral medulla. Poss sm focal
  area of acute ischemia L pons.
• MRA-small vertebral and basilar arteries, likely
  stenosis. PCAs not well seen. Mild ASD R MCA
  and R A1 segment.
• Echo-nl LV fxn, EF 55-60, no thrombus.
• CT angiogram-occluded R vert over 3cm from C2 to
  foramen magnum, stenosis L vert level of C1,
  irreg narrow- basilar art.

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Therapeutic Options (Medical)

• WASID-warfarin poorer than ASA. Higher incidence
  of primary endpoint (post qualifying TIA or
  ischemic stroke)
• ESPRIT-warfarin not more effective than ASA for
  secondary prevention, but ASA/DIP is superior to
  ASA alone
• In both studies, warfarin associated with
  increased risk of bleeding

-Warfarin vs Aspirin for Symptomatic Intracranial
Stenosis Subgroup analysis from WASID. S.E.
Kasner et al. Neurology 2006 67
1275-1278 ESPRIT Study Group. Lancet 2006, May
20 367 (9523) pg 1665-73 ESPRIT Study Group.
Lancet 2007, Feb 6 (2) 115-24
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Case Report-medical Treatment and Follow-up Care I

• On baby ASA, started on Plavix in ED
• Changed to baby ASA Aggrenox (ASA 25mg/DIP
  200mg) BID
• Discharged home on 12/18/07
• Returned 12/22/07 with worsening sxs of
  dizzyness (although gait had improved)

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Case Report-medical Treatment and Follow-up Care
II

• 2nd admission-started on lovenox (1mg/kg BID) and
  coumadin 5mg daily (to goal INR 2-3)
• Continued HCTZ, Ezetimibe/ Simvastatin,
  Metformin, Atenolol, Lisinopril, Nifedipine
• Improvement in nystagmus, sensation and gait
• Given 300mg Plavix load 12/27/06

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Outcomes and Sequelae

• Ischemia/infarct of brainstem, cerebellum
• After VBI TIA, 5 year risk of stroke is 22-35
• Optimal management of vertebral artery stenosis
  not well delineated compared to carotid artery
  stenosis

JC Wehman et al. Atherosclerotic occlusive
extracranial vertebral artery disease
indications for intervention, endovascular
techniques, short-term and long-term results. J
Interv Cardiol 2004 17 219-32
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Interventional Options

• Symptomatic high-grade stenosis (gt70) considered
  for intervention
• PTA alone or with stent placement
• Higher restenosis rates- PTA alone
• UVA-self disclosed lt10 rate of complications
• In our patient, 2.25 mm coronary cobalt stent
  deployed Jan 5, 2007

Warfarin vs Aspirin for Symptomatic Intracranial
Stenosis Subgroup analysis from WASID. S.E.
Kasner et al. Neurology 2006 67 1275-1278
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Interventional Outcomes

• Severity of SIAS did not present higher stroke
  risk after PTA stent.
• Dissection and rupture complicate up to
  8 of angioplasties for symptomatic intracranial
  stenosis.
• 2 case series report 6 stroke risk.
• Published data on gt300 interventions show 0.3
  risk of death, 5.5 risk of peri-procedural
  neurologic complic.

Comparison of Elective Stenting of Severe vs
Moderate Intracranial Atherosclerotic Stenosis.
Jiang, WJ et al. Neurology 2007. 68
420-426 Stenting of VB Arteries in Symptomatic
Atherosc. Disease Acute Occlusion Case Series
Rev of Lit. Eberhardt O. et al. J Vasc Surg
2006 431145-54
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Post-Stent course

• Continued on baby ASA and Plavix
• Lipid management with niaspan
  ezetimibe/simvastatin
• Started driving again in February
• Scheduled for f/u Angiogram at UVA
• Re-admitted in early April for worsening
  dizzyness-MRI - for stroke
• Long-term Prognosis?

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Take Home Points

• ASA/DIP superior to ASA in secondary prevention
  after arterial stroke
• Anti-coagulations main role is in cardioembolic
  stroke
• PTA/Stenting can be an appropriate treatment for
  VBI
• When medical tx fails
• When complication rates low
• When patients are IDed appropriately

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Review Questions

• a. Which of the following is the best initial
  treatment in posterior circulation stroke?

•      ii.  Warfarin to goal INR 2-3
•      iii. Asprin 1300mg daily
•      iv. Aggrenox 25/200mg BID
•      v.  Heparin to goal PTT 50-80

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Review Questions

• b. The left vertebral artery is dominant in what
  of the healthy population?

• i. 10
•      ii. 25
•      iii. 50
•      iv. 75

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Review Questions

• c.  A common complication of Percutaneous
  Transluminal Angioplasty, especially if performed
  without stent?

•      i.   Arterial dissection
•      ii.  Neurologic dysfunction
• iii. Arterial restenosis
• iv. Embolus

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Patient/Family Resources.

• National Stroke Association- www.stroke.org
• American Stroke Association- www.strokeassociation
  .org
• National Institute of Neurologic Disorders and
  Stroke- www.ninds.nih.gov