Early MRI-negative posterior circulation stroke presenting as acute dizziness

Area of Science:

• Neurology
• Neuroimaging
• Stroke Medicine

Background:

• Posterior circulation stroke (PCS) can present with acute dizziness/vertigo, often with negative initial DWI/MRI.
• Accurate and timely diagnosis of PCS is crucial to prevent stroke progression.

Purpose of the Study:

• To determine the frequency, clinical, and radiological features of DWI/MRI-negative PCS in patients with acute dizziness/vertigo.
• To evaluate the efficacy of clinical evaluation and perfusion-weighted imaging (PWI) in predicting final stroke in this patient group.

Main Methods:

• Prospective analysis of 850 patients with PCS and acute dizziness/vertigo from a 7-year stroke registry.
• Initial DWI/MRI was negative in 35 patients (4.1%).
• Clinical evaluation included neurological examination, HINTS protocol (head impulse, nystagmus, and test-of-skew), and equilibrium assessment, with PWI used in select cases.

Main Results:

• Of 35 DWI/MRI-negative patients, 31 had prolonged dizziness/vertigo. 16/35 had focal neurological signs, and 18/34 had profound imbalance.
• PWI was positive in 12/26 patients with negative DWI.
• The lateral medulla was the usual lesion site (n=18); 83% had small strokes, and 54% had large vessel strokes.

Conclusions:

• Systematic clinical evaluation (neurological, neuro-otological, HINTS plus) achieved 83% sensitivity for predicting final stroke.
• Combining clinical evaluation with PWI reached 100% sensitivity for stroke prediction.
• An integrated approach with clinical assessment and PWI accurately diagnoses PCS presenting with acute dizziness/vertigo, identifying high-risk patients for prompt treatment.