Abstract
Background: Diagnosing stroke as a cause of acute vertigo, dizziness, or double vision remains a challenge, because symptom characteristics can be variable. The purpose of this study was to prospectively investigate lesion-symptom relationships in patients with acute vestibular or ocular motor stroke.Methods: Three hundred and fifty one patients with acute and isolated vestibular or ocular motor symptoms of unclear etiology were enrolled in the EMVERT lesion trial. Symptom quality was assessed by the chief complaint (vertigo, dizziness, double vision), symptom intensity by the visual analog scale, functional impairment by EQ-5D-5L, and symptom duration by daily rating. Acute vestibular and ocular motor signs were registered by videooculography. A standardized MRI (DWI-/FLAIR-/T2-/T2*-/3D-T1-weighted sequences) was recorded within 7 days of symptom onset. MRIs with DWI lesions were further processed for voxel-based lesion-symptom mapping (VLSM).Results: In 47 patients, MRI depicted an acute unilateral stroke (13.4%). The chief complaints were dizziness (42.5%), vertigo (40.4%) and double vision (17.0%). Lesions in patients with vertigo or dizziness showed a large overlap in the cerebellar hemisphere. VLSM indicated that strokes in the medial cerebellar layers 7b, 8, 9 were associated with vertigo, strokes in the lateral cerebellar layer 8, crus 1, 2 with dizziness, and pontomesencephalic strokes with double vision. Symptom intensity and duration varied largely between patients. Higher symptom intensity and longer duration were associated with medial cerebellar lesions. Hemispheric lesions of the cortex were rare and presented with milder symptoms of shorter duration.Conclusions: Prospective evaluation of patients with acute vestibular or ocular motor stroke revealed that symptom quality, intensity and duration were not suited to differentiating peripheral from central etiologies. Lesions in the lateral cerebellum, thalamus, or cortex presented with unspecific, mild and transient symptoms prone to being misdiagnosed.
Highlights
Vertigo, dizziness or double vision may be symptoms of an acute cerebral ischemia or hemorrhage [1]
Four hundred and eighty-nine patients were excluded, because of the following reasons: definite peripheral vestibular or ocular motor disorders (n = 203); strokes with accompanying non-vestibular symptoms (n = 15); decline to participate (n = 186); incapability to be included for other reasons (n = 85)
Skew deviation appeared in 26% of patients with vertigo, 20% of patients with dizziness and 25% of patients with double vision
Summary
Dizziness or double vision may be symptoms of an acute cerebral ischemia or hemorrhage [1]. Cerebral lesions presenting with vertigo, dizziness, or double vision mostly involve vestibular and ocular motor circuits in the brainstem and cerebellum, whereas thalamo-cortical networks are affected only occasionally [6, 7]. The reason for this lesion distribution can be found in the functional anatomy of the bilaterally organized central vestibular system, which converts direction-specific signals of each labyrinth into more global position-in-space signals along the ascending vestibular projections [8]. Diagnosing stroke as a cause of acute vertigo, dizziness, or double vision remains a challenge, because symptom characteristics can be variable. The purpose of this study was to prospectively investigate lesion-symptom relationships in patients with acute vestibular or ocular motor stroke
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