Introduction: The aim of the study was to investigate the relationship between acute cerebrovascular infarction and risk factors in the patients presented to the emergency department (ED) with isolated vertigo symptoms. Materials and Methods: Ninety patients presented with isolated acute vertigo attack and/or dizziness symptoms were retrospectively analyzed. The criteria for inclusion in the study were patients with ≥18 years of age and patients with acute vertigo and/or dizziness and ischemic infarction on diffusion-weighted magnetic resonance imaging or computed tomography. The exclusion criteria were patients with peripheral vertigo, dizziness associated with a systemic disease, and incomplete data. The patients were categorized into two groups as cerebellar and noncerebellar according to the infarct localization. Results: The mean age of the patients was 60.31 ± 15.18 years and 43 patients were male. Of the patients, 34 (37.8) had cerebellar infarction and 56 (62.2) had noncerebellar infarction. There was no statistically significant difference between the two groups except for hyperlipidemia (67.6% in the cerebellar group, 35.7% in the noncerebellar group; P = 0.005). The multivariate logistic regression analysis revealed that hyperlipidemia (odds ratio [OR] = 3.233; 95% confidence interval [CI] = 1.144–9.136; P = 0.027) and imbalance (OR = 4.064; 95% CI = 1.271–12.995; P = 0.018) were the strongest indicators of cerebellar infarction in the patients with isolated vertigo. Conclusion: While the presence of accompanying nausea and vomiting in the ED is indicative of noncerebellar infarction, the risk factors of hyperglycemia and/or hyperlipidemia are strong indicators for the diagnosis of acute cerebellar infarction in isolated vertigo patients.
Keywords: Cerebellum, dizziness, emergency department, vertigo
|How to cite this URL:|
Bedel C, Korkut M. The relationship of clinical and laboratory factors with acute isolated vertigo and cerebellar infarction. Indian J Med Spec [Epub ahead of print] [cited 2020 Aug 5]. Available from: http://www.ijms.in/preprintarticle.asp?id=291050
| Introduction|| |
Vertigo or dizziness is one of the most common complaints in the emergency department (ED), affecting 20%–30% of the general population. Vertigo is defined as the perception of motion when no motion occurs, and patients often talk about the sensation of imaginary spinning. Vertigo has been determined as the primary symptom in about 4% of ED visits.
Vertigo is first divided into two main groups as central or peripheral. Those of peripheral etiology are usually benign. Although central vertigo is less common, it can be life-threatening and is often associated with dysarthria, diplopia, ataxia, or other neurological deficits. However, there is no definitive clue to differentiate between central and peripheral vertigo types in patients presenting with vertigo (isolated vertigo) in the absence of other neurological findings. In a prospective study conducted by Norrving et al. on 24 patients, cerebellar infarction was identified in one-fourth of patients with isolated vertigo.
Cerebral infarction can be identified by diffusion-weighted magnetic resonance imaging (MRI) or computed tomography (CT) with its high sensitivity and specificity shortly after the onset of clinical symptoms. If misdiagnosed, patients may get worse, resulting in permanent disability or a life-threatening course. Such patients can be properly diagnosed at an early stage, and if an appropriate treatment could be given, patients may achieve a significant improvement.
Therefore, we performed a single-center retrospective analysis of patients with isolated vertigo and cerebral infarction to determine the factors related to the cerebrovascular etiology.
| Materials and Methods|| |
In this study designed as a retrospective cohort study, our patients were selected among patients who presented to the ED with isolated acute vertigo attack between January 1, 2018, and January 1, 2019. The first neurological examination of the patients was performed by ED physicians. The patients who did not respond to the treatment in the emergency room were evaluated by a neurologist.
Vertigo and dizziness were defined according to the internationally accepted guidelines., Vertigo is the sensation of self-motion when no self-motion occurs or the sensation of distorted self-motion during an otherwise normal head movement. Dizziness, on the other hand, is the sensation of disturbed or impaired spatial orientation without a false or distorted sense of motion.,,
The hospitalized patients with ischemic infarction on CT and/or MRI taken in the ED were included in the study. The patients who were retrospectively scanned were categorized into cerebellar and noncerebellar groups according to the infarct localization on CT/MRI.
All patients were retrospectively scanned through the hospital information record system. In laboratory studies, leukocyte, neutrophil, lymphocyte, monocyte, platelet, glucose, urea, and creatinine values were evaluated in the blood samples taken during the first admission to the ED.
The data of the patients regarding risk factors, admission symptoms and findings, inhospital mortality and length of hospital stay, and demographic characteristics were collected. The criteria for inclusion in the study were patients with ≥18 years of age and patients with acute vertigo and/or dizziness and ischemic infarction on cranial MRI and/or CT. The exclusion criteria were patients with peripheral vertigo, dizziness associated with a systemic disease, and incomplete data. The patient flowchart is shown in [Figure 1].
In statistical analyses, standard deviation and mean values were calculated for continuous variables and median values were calculated for nonparametric data. The Chi-square test was performed for each of the independent variables and they were compared. Multiple regression analysis was performed to understand the effect of those found to be statistically significant on acute vertigo complaint. The descriptive statistical analysis of all variables was carried out using SPSS 18.0 statistical package (SPSS Inc. Chicago, Illinois, USA).
| Results|| |
Throughout the study period, there were 234 patients admitted to the ED for vertigo and hospitalized. Of these patients, 144 were excluded and 90 patients were included in the final analysis; the detailed study flowchart is shown in [Figure 1]. Of the patients, 34 (37.8) had cerebellar infarction and 56 (62.2) had noncerebellar infarction. The mean age of the patients was 60.31 ± 15.18 years and 43 (47.8%) patients were male. The mean age of the patients with cerebellar infarction (64.74 ± 13.55) was significantly higher than the mean age of the noncerebellar group (57.63 ± 15.59) (P = 0.023). Hypertension, diabetes, and coronary heart disease were the most common risk factors in both the groups. Hyperlipidemia was significantly higher in the cerebellar group (23 [67.6%]) than in the noncerebellar group (20 [35.7%]) (P = 0.005). The mean length of hospital stay of the patients was 7.04 ± 3.92 days. Mortality was observed in one patient due to comorbid conditions. There was no statistically significant difference between the two groups in terms of other basal characteristics [Table 1].
|Table 1: Characteristics and vascular risk factors of cerebellar and noncerebellar infarction patients presenting with acute vertigo|
Click here to view
The patients with cerebellar infarction had significantly higher nystagmus frequency than those with noncerebellar infarction (8 [23.5%], 4 [7.1%]; P = 0.027). In addition, the percentage of imbalance was significantly higher in the patients with cerebellar infarction than in those with noncerebellar infarction (17 [50%], 15 [26.8%]; P = 0.04). Nausea and vomiting were statistically significantly higher in the patients with noncerebellar infarction than in those with cerebellar infarction (41 [73.2%], 17 [50%]; P = 0.04). Despite the common correlation with rotational vertigo and body posture in both the groups, there was no statistically significant difference (P > 0.05). There was no statistically significant difference between the two groups in terms of other accompanying symptoms and findings (P > 0.05) [Table 2].
The blood glucose level of the patients with cerebellar infarction was significantly higher than those with noncerebellar infarction (184.64 ± 104.63, 139.42 ± 63.36; P = 0.03). Other laboratory parameters were not significantly different between the groups (P > 0.05) [Table 3].
|Table 3: Laboratory results in patients with cerebellar and noncerebellar infarction presenting with isolated vertigo|
Click here to view
The multivariate logistic regression analysis revealed that hyperlipidemia (odds ratio [OR] = 3.233; 95% confidence interval [CI] = 1.144–9.136; P = 0.027) and imbalance (OR = 4.064; 95% CI = 1.271–12.995; P = 0.018) were the strongest indicators of cerebellar infarction in the patients with isolated vertigo [Table 4].
|Table 4: Results of logistic regression analysis in patients presenting with acute isolated vertigo|
Click here to view
| Discussion|| |
Isolated vertigo is one of the most common clinical symptoms in the society and one of the most common causes of admission to the hospital. In a study conducted in the USA, it was reported that 3.5% of adults experience vertigo symptoms. In another study, this rate was found to be 5% and it was stated that the vast majority of these patients visited the doctor. The studies have indicated that isolated vertigo may be the only symptom of cerebral infarction, and in these studies, this rate varies between 0.7% and 11%., In our study, we hospitalized 90 (38.5) of 234 patients who presented to the ED with isolated vertigo due to cerebral infarction. Of these patients, 37.8 had cerebellar infarction, while 62.2 had noncerebellar infarction. Such a higher rate in our study may be due to the difference in the inclusion and exclusion criteria.
Hypertension, coronary artery disease, and diabetes were the most common causes of cerebral infarction in our study. When we compared the cerebellar infarction and noncerebellar infarction groups, we found that only the percentage of hyperlipidemia was significantly higher in the patients with cerebellar infarction. In a study, it was reported that patients with three or more risk factors had a greater risk of stroke. In another study, Aluçlu et al. reported the most common risk factors as hypertension (78.1%), smoking (50%), and atrial fibrillation (50%). In a study by Wintermark et al., hypertension, smoking, atrial fibrillation, and hypercholesterolemia were the most common risk factors. In our study, hypertension, coronary artery disease, and hyperlipidemia were the risk factors present in more than half of the patients. Moreover, unlike other studies, cerebellar infarction was more common in the patients with hyperlipidemia (P = 0.005). As it is known, atrial fibrillation and coronary artery disease are important risk factors for stroke. Although approximately one-fourth of our patients had atrial fibrillation as a risk factor and about half of them had coronary artery disease, these factors did not make a statistically significant difference between noncerebellar and cerebellar infarction groups.
In our study, we found that nystagmus, imbalance, and nausea and vomiting were significantly different among the symptoms and findings of cerebellar and noncerebellar patient groups. In a recent study, the most common symptoms were nausea and vomiting (45.9%) and rotational vertigo (45.9%) in 227 patients with cerebral infarction. In another study, it was reported that most of the patients presented with vertigo had cerebellar infarction accompanying imbalance. In the study by Calic et al., nausea and vomiting (33.4%), imbalance in walking (32.6%), and headache (23.1%) were the most common symptoms. In another study, the most common complaints were nausea and vomiting (70%), balance disorder (58%), visual impairment (2%), and hearing impairment (2%). We think that this difference in the studies is due to sample selection and size.
In their study, Buck et al. reported that patients with infarction had a significant increase in leukocyte and neutrophil count compared to those without infarction. In another study, it was reported that there was an increase in leukocyte and neutrophil after a transient ischemic attack. In a study by Greisenegger et al., it was noted that there was a relationship between mean platelet volume (MPV) and platelet values with stroke. Unlike the literature, our study found no relationship with simple hemogram parameters (neutrophil, lymphocyte, MPV, and platelet) between the groups. In our study, only the blood glucose levels of the patients with cerebellar infarction were higher than that of those without cerebellar infarction (P = 0.03). This result is consistent with the literature. Considering the results in our study, while diabetes is not a risk factor for isolated vertigo between noncerebellar and cereballar groups, hyperglycemia has made a statistically significant difference between the groups, and this difference may be related to the cause of stress hyperglycemia. Stress hyperglycemia occurs in about 38% of patients hospitalized for acute illness, and about one-third of these do not have a history of diabetes. It is common in cases of sepsis, trauma, burns, cardiac surgery, and stroke.
First of all, our study was conducted retrospectively in a single center and with a relatively small sample size. Second, physical examination, diagnosis, and treatment of the disease were performed by different physicians and neurologists. Longer-term prospective studies are required to more accurately determine the diagnosis of patients evaluated for vertigo.
| Conclusion|| |
While the presence of accompanying nausea and vomiting accompanying in the ED is indicative of noncerebellar infarction, the risk factors of hyperglycemia and/or hyperlipidemia are strong indicators for the diagnosis of acute cerebellar infarction in isolated vertigo patients.
Ethics Committee approval was received for this study from the local Ethics Committee (2019-131).
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Savitz SI, Caplan LR. Vertebrobasilar disease. N
Engl J Med 2005;352:2618-26.
Parker IG, Hartel G, Paratz J, Choy NL, Rahmann A. A systematic review of the reported proportions of diagnoses for dizziness and vertigo. Otol Neurotol 2019;40:6-15.
Edlow JA. Diagnosing patients with acute-onset persistent dizziness. Ann Emerg Med 2018;71:625-31.
Pan Q, Zhang Y, Long T, He W, Zhang S, Fan Y, et al
. Diagnosis of vertigo and dizziness syndromes in a neurological outpatient clinic. Eur Neurol 2018;79:287-94.
Iwasaki S, Yamasoba T. Dizziness and imbalance in the elderly: Age-related decline in the vestibular system. Aging Dis 2015;6:38-47.
Norrving B, Magnusson M, Holtås S. Isolated acute vertigo in the elderly; vestibular or vascular disease? Acta Neurol Scand 1995;91:43-8.
Zuo L, Zhan Y, Liu F, Chen C, Xu L, Calic Z, et al
. Clinical and laboratory factors related to acute isolated vertigo or dizziness and cerebral infarction. Brain Behav 2018;8:e01092.
Crespi V. Dizziness and vertigo: An epidemiological survey and patient management in the emergency room. Neurol Sci 2004;25 Suppl 1:S24-5.
Kerber KA, Brown DL, Lisabeth LD, Smith MA, Morgenstern LB. Stroke among patients with dizziness, vertigo, and imbalance in the emergency department: A population-based study. Stroke 2006;37:2484-7.
Doijiri R, Uno H, Miyashita K, Ihara M, Nagatsuka K. How commonly is stroke found in patients with isolated vertigo or dizziness attack? J Stroke Cerebrovasc Dis 2016;25:2549-52.
Lee H, Sohn SI, Cho YW, Lee SR, Ahn BH, Park BR, et al
. Cerebellar infarction presenting isolated vertigo: Frequency and vascular topographical patterns. Neurology 2006;67:1178-83.
Aluçlu MU, Yücel Y. Etiology, localization and prognosis in cerebellar infarctions. Dicle Med J 2006;33:31-5.
Wintermark M, Reichhart M, Cuisenaire O, Maeder P, Thiran JP, Schnyder P, et al
. Comparison of admission perfusion computed tomography and qualitative diffusion- and perfusion-weighted magnetic resonance imaging in acute stroke patients. Stroke 2002;33:2025-31.
Calic Z, Cappelen-Smith C, Cuganesan R, Anderson CS, Welgampola M, Cordato DJ. Frequency, aetiology, and outcome of small cerebellar infarction. Cerebrovasc Dis Extra 2017;7:173-80.
Aktaş A, Durak VA, Aydın SA. Prospective investigation of patients admitted to the emergency department with vertigo complaint. Uludaǧ Univers Med J 2012;45:71-5.
Buck BH, Liebeskind DS, Saver JL, Bang OY, Yun SW, Starkman S, et al
. Early neutrophilia is associated with volume of ischemic tissue in acute stroke. Stroke 2008;39:355-60.
Ross AM, Hurn P, Perrin N, Wood L, Carlini W, Potempa K. Evidence of the peripheral inflammatory response in patients with transient ischemic attack. J Stroke Cerebrovasc Dis 2007;16:203-7.
Greisenegger S, Endler G, Hsieh K, Tentschert S, Mannhalter C, Lalouschek W. Is elevated mean platelet volume associated with a worse outcome in patients with acute ischemic cerebrovascular events? Stroke 2004;35:1688-91.
Kılıç S, Gültekin M, Soyuer F, Ünlühizarcı K, Soyuer A. Effects of transient hyperglycemia on stroke prognosis in patients with acute ischemic stroke. Türk Beyin Damar Hast Derg 2012;18:72-6.
Jain P, Shah H. Relationship between insulin metabolic disorders and pediatric stress hyperglycemia. J Adv Med Dent Scie Res 2019;7:154-7.
Department of Emergency Medicine, Health Science University Antalya Training and Research Hospital, Kazim Karabekir Street, Muratpasa, 07100, Antalya
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4]