History
Mr. Hui was a 60-year-old gentleman. He was an ex-chronic smoker for 20 years and had a history of untreated hypertension.
After reviewing his history, the presumed vertigo was re-characterized as an acute onset unsteady gait upon waking up 1 week prior to his admission.
The gait symptom was persistent, associated with a sense of disequalibrium, exacerbated by walking / head turning, and relieved by holding a static head and body posture.
He became homebound as a result, and was barely able to ambulate with furniture cruising. He decided to seek medical attention after an episode of fall.
The overall disease trajectory was worst at onset with subsequent partial recovery.
Physical examination
His blood pressure at presentation was significantly elevated at 230/150.
The initial neurological examination was thought to be normal.
A repeated examination revealed mild hypometric horizontal saccades in both directions, subtle oculopulsion to the right, right upper limb pronator drift, right-sided ataxia, and a failure to perform tandem walking.
Investigations
A CT scan of the brain demonstrated bilateral subcortical and deep lacunar infarcts of symmetrical ischemic burden. An ECG showed evidence of left ventricular hypertrophy. Baseline blood tests were unremarkable.
Thought process
This was a syndrome of acute onset unilateral ataxia with interval partial recovery.
The pathology was likely localized to the cerebral level, specifically involving the right cerebellum and medulla.
Given the strong vascular risk factors, an acute ischemic stroke was the most probable etiology.
Next steps
An MRI scan of the brain was arranged to localize the acute infarct.