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Stroke and Transient Ischemic Attacks Over the past few days you have had three brief spells of vertigo and double vision, each lasting about five minutes. You now experience per­ sis­ tent vertigo and severe imbalance. You cannot stand up even with support. You can speak, but your speech is slurred and your right hand is clumsy so that you have difficulty dialing the phone for help.­ People often ask us ­ whether their dizziness might be due to a stroke or might be a warning of a stroke to come. Anyone at any age can have a stroke, but some groups have a higher risk of stroke than ­ others. So our answer is yes, especially if you are in the age range for stroke (usually over 60) and/or if you have other risk ­ factors for stroke such as high blood pressure and diabetes. But even then stroke is a relatively rare cause for dizziness compared to other, more benign ­ causes. Most strokes result from blockage of an artery depriving part of the brain of its blood supply. This ­ causes infarction, an area of necrosis (cell death) in the brain, which can be extensive, especially if the blood vessel involved is a large one. If the interruption of blood flow is milder, ­ there may be minimal or no damage. ­ These milder events are called transient ischemic attacks (TIAs). Sometimes a TIA can be a warning of an impending stroke. Bleeding into the brain can also cause stroke, CHAPTER  6 A Single Bout of Dizziness for Days 100 but the person having this kind of stroke usually has rapidly progressive and multiple neurological symptoms, including impaired consciousness or loss of consciousness. The symptoms of such a stroke would rarely be confused with the symptoms of other benign ­ causes of dizziness. Vertigo typically results from interruption of normal blood flow to the brain stem and cerebellum, supplied by the vertebral and basilar arteries. The two vertebral arteries run up the back of the neck and join together at the base of the brain to form the basilar artery, which runs along the brain stem to supply the brain stem and cerebellum (figure 4). Low blood flow in this vertebrobasilar artery system commonly ­ causes vertigo and imbalance. This is ­ because the vertebrobasilar artery system supplies brain stem and cerebellar areas that are critical for normal balance. It also supplies blood to both inner ears. By contrast, vertigo does not result from blockage of the carotid arteries, the arteries that run up the front of the neck and supply most of the ce­ re­ bral cortex and the ret­ ina of both eyes. Typical symptoms of carotid artery disease include one-­ sided visual loss, impaired speech and language, and weakness and numbness on one side of the face and body. A question that has plagued neurologists for more than a­ century is ­ whether vertigo and imbalance can be the only symptoms of a vertebrobasilar stroke and TIA or ­ whether ­ there should always be other associated neurological symptoms.­ After all, the brain stem is packed with critical centers for controlling eye movements, balance, face and body sensation, and coordinated hand and leg movements. Insufficient blood flow to the brain stem should result in a list of neurological symptoms, not just dizziness. It nearly always does. In fact­ there is a general dictum in neurology that isolated vertigo without other associated neurological symptoms indicates a peripheral vestibular cause—in other words, isolated vertigo Stroke and Tr ansient Ischemic At tack s 101 must originate from damage to the inner ear or vestibular nerve. ­ There are exceptions to the rule, however, and in recent years it has become clear that vertigo and imbalance are sometimes the only symptoms of TIA or stroke associated with decreased blood flow within the vertebrobasilar system, particularly when the decreased blood flow selectively involves the cerebellum. But the rare exceptions to the dictum do not negate the concept ­ behind it. Vertigo originating from damage to Figure 4 ​The arterial circulation to the brain stem and cerebellum. The two vertebral arteries join together to form the basilar artery. The main branches are the posterior inferior cerebellar artery (PICA), the anterior inferior cerebellar artery (AICA), the superior cerebellar artery (SCA), and the posterior ce­ re­ bral artery (PCA). See text for details. Superior cerebellar artery (SCA) Brain stem Basilar artery Vertebral arteries Anterior inferior cerebellar artery (AICA) Posterior inferior cerebellar artery (PICA) Posterior cerebral artery (PCA) Cerebellum A Single Bout of Dizziness for Days...


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