The Cerebellum

, Volume 15, Issue 6, pp 781–788 | Cite as

Recent Advances in Cerebellar Ischemic Stroke Syndromes Causing Vertigo and Hearing Loss

Review

Abstract

Cerebellar ischemic stroke is one of the common causes of vascular vertigo. It usually accompanies other neurological symptoms or signs, but a small infarct in the cerebellum can present with vertigo without other localizing symptoms. Approximately 11 % of the patients with isolated cerebellar infarction simulated acute peripheral vestibulopathy, and most patients had an infarct in the territory of the medial branch of the posterior inferior cerebellar artery (PICA). A head impulse test can differentiate acute isolated vertigo associated with PICA territory cerebellar infarction from more benign disorders involving the inner ear. Acute hearing loss (AHL) of a vascular cause is mostly associated with cerebellar infarction in the territory of the anterior inferior cerebellar artery (AICA), but PICA territory cerebellar infarction rarely causes AHL. To date, at least eight subgroups of AICA territory infarction have been identified according to the pattern of neurotological presentations, among which the most common pattern of audiovestibular dysfunction is the combined loss of auditory and vestibular functions. Sometimes acute isolated audiovestibular loss can be the initial symptom of impending posterior circulation ischemic stroke (particularly within the territory of the AICA). Audiovestibular loss from cerebellar infarction has a good long-term outcome than previously thought. Approximately half of patients with superior cerebellar artery territory (SCA) cerebellar infarction experienced true vertigo, suggesting that the vertigo and nystagmus in the SCA territory cerebellar infarctions are more common than previously thought. In this article, recent findings on clinical features of vertigo and hearing loss from cerebellar ischemic stroke syndrome are summarized.

Keywords

Cerebellum Ischemic stroke Vertigo Hearing loss Cerebellar infarction 

Notes

Acknowledgments

Two authors contributed equally as co-first authors to this work.

Author Contribution

Dr. Lee conducted the design and conceptualization of the study, interpretation of the data, and drafting and revising of the manuscript.

Drs. Kim and Yi wrote the manuscript and analyzed and interpreted the data.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no competing interests.

Dr. Lee serves on the editorial boards of Frontiers in Neuro-otology, Research in Vestibular Science and Current Medical Imaging Review, and received research support from DAWOONG PHARMACEUTICAL, Co. Ltd.

Drs. Kim and Yi report no disclosures.

References

  1. 1.
    Savitz SI, Caplan LR. Vertebrobasilar disease. N Engl J Med. 2005;352:2618–26.CrossRefPubMedGoogle Scholar
  2. 2.
    Macdonell RA, Kalnins RM, Donnan GA. Cerebellar infarction: natural history, prognosis, and pathology. Stroke. 1987;18:849–55.CrossRefPubMedGoogle Scholar
  3. 3.
    Bogousslavsky J, Van Melle G, Regli F. The Lausanne Stroke Registry: analysis of 1,000 consecutive patients with first stroke. Stroke. 1988;19:1083–92.CrossRefPubMedGoogle Scholar
  4. 4.
    Lee H, Yi HA, Cho YW, Sohn CH, Whitman GT, Ying S, et al. Nodulus infarction mimicking acute peripheral vestibulopathy. Neurology. 2003;60:1700–2.CrossRefPubMedGoogle Scholar
  5. 5.
    Lee H, Cho YW. A case of isolated nodulus infarction presenting as a vestibular neuritis. J Neurol Sci. 2004;221:117–9.CrossRefPubMedGoogle Scholar
  6. 6.
    Chen W, Fang J, Dong YR, Di Y, Li W. Teaching NeuroImages: isolated vertigo and imbalance due to deep border zone cerebellar infarct. Neurology. 2011;77, e122.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Kim DU, Han MK, Kim JS. Isolated recurrent vertigo from stenotic posterior inferior cerebellar artery. Otol Neurotol. 2011;32:180–2.CrossRefPubMedGoogle Scholar
  8. 8.
    Norrving B, Magnusson M, Holtas S. Isolated acute vertigo in the elderly; vestibular or vascular disease? Acta Neurol Scand. 1995;91:43–8.CrossRefPubMedGoogle Scholar
  9. 9.
    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.CrossRefPubMedGoogle Scholar
  10. 10.
    Lee H. Neuro-otological aspects of cerebellar stroke syndrome. J Clin Neurol. 2009;5:65–73.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Choi KD, Lee H, Kim JS. Vertigo in brainstem and cerebellar strokes. Curr Opin Neurol. 2013;26:90–5.CrossRefPubMedGoogle Scholar
  12. 12.
    Lee H. Isolated vascular vertigo. J Stroke. 2014;16:124–30.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Lee H, Sohn SI, Jung DK, Cho YW, Lim JG, Yi SD, et al. Sudden deafness and anterior inferior cerebellar artery infarction. Stroke. 2002;33:2807–12.CrossRefPubMedGoogle Scholar
  14. 14.
    Lee H. Recent advances in acute hearing loss due to posterior circulation ischemic stroke. J Neurol Sci. 2014;338:23–9.CrossRefPubMedGoogle Scholar
  15. 15.
    Lee H, Baloh RW. Sudden deafness in vertebrobasilar ischemia: clinical features, vascular topographical patterns, and long-term outcome. J Neurol Sci. 2005;228:99–104.CrossRefPubMedGoogle Scholar
  16. 16.
    Newman-Toker DE, Kattah JC, Alvernia JE, Wang DZ. Normal head impulse test differentiates acute cerebellar strokes from vestibular neuritis. Neurology. 2008;70:2378–85.CrossRefPubMedGoogle Scholar
  17. 17.
    Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009;40:3504–10.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Chen L, Lee W, Chambers BR, Dewey HM. Diagnostic accuracy of acute vestibular syndrome at the bedside in a stroke unit. J Neurol. 2011;258:855–61.CrossRefPubMedGoogle Scholar
  19. 19.
    Newman-Toker DE, Kerber KA, Hsieh YH, Pula JH, Omron R, Saber Tehrani AS, et al. HINTS outperforms ABCD2 to screen for stroke in acute continuous vertigo and dizziness. Acad Emerg Med. 2013;20:986–96.CrossRefPubMedGoogle Scholar
  20. 20.
    Saber Tehrani AS, Kattah JC, Mantokoudis G, Pula JH, Nair D, Blitz A, et al. Small strokes causing severe vertigo: frequency of false-negative MRIs and nonlacunar mechanisms. Neurology. 2014;83:169–73.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Cnyrim CD, Newman-Toker D, Karch C, Brandt T, Strupp M. Bedside differentiation of vestibular neuritis from central “vestibular pseudoneuritis”. J Neurol Neurosurg Psychiatry. 2008;79:458–60.CrossRefPubMedGoogle Scholar
  22. 22.
    Kim HA, Lee H. Isolated vestibular nucleus infarction mimicking acute peripheral vestibulopathy. Stroke. 2010;41:1558–60.CrossRefPubMedGoogle Scholar
  23. 23.
    Kirchner H, Kremmyda O, Hufner K, Stephan T, Zingler V, Brandt T, et al. Clinical, electrophysiological, and MRI findings in patients with cerebellar ataxia and a bilaterally pathological head-impulse test. Ann N Y Acad Sci. 2011;1233:127–38.CrossRefPubMedGoogle Scholar
  24. 24.
    Kim HA, Lee H. Recent advances in central vestibular syndromes of a vascular cause. J Neurol Sci. 2012;321:17–22.CrossRefPubMedGoogle Scholar
  25. 25.
    Park HK, Kim JS, Strupp M, Zee DS. Isolated floccular infarction: impaired vestibular responses to horizontal head impulse. J Neurol. 2013;260:1576–82.CrossRefPubMedGoogle Scholar
  26. 26.
    Kim HJ, Lee SH, Park JH, Choi JY, Kim JS. Isolated vestibular nuclear infarction: report of two cases and review of the literature. J Neurol. 2014;261:121–9.CrossRefPubMedGoogle Scholar
  27. 27.
    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.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Huh YE, Kim JS. Patterns of spontaneous and head-shaking nystagmus in cerebellar infarction: imaging correlations. Brain. 2011;134:3662–71.CrossRefPubMedGoogle Scholar
  29. 29.
    Baier B, Dieterich M. Incidence and anatomy of gaze-evoked nystagmus in patients with cerebellar lesions. Neurology. 2011;76:361–5.CrossRefPubMedGoogle Scholar
  30. 30.
    Moon IS, Kim JS, Choi KD, Kim MJ, Oh SY, Lee H, et al. Isolated nodular infarction. Stroke. 2009;40:487–91.CrossRefPubMedGoogle Scholar
  31. 31.
    Kim HA, Yi HA, Lee H. Apogeotropic central positional nystagmus as a sole sign of nodular infarction. Neurol Sci. 2012;33:1189–91.CrossRefPubMedGoogle Scholar
  32. 32.
    Kim SH, Park SH, Kim HJ, Kim JS. Isolated central vestibular syndrome. Ann N Y Acad Sci. 2015;1343:80–9.CrossRefPubMedGoogle Scholar
  33. 33.
    Lee SH, Park SH, Kim JS, Kim HJ, Yunusov F, Zee DS. Isolated unilateral infarction of the cerebellar tonsil: ocular motor findings. Ann Neurol. 2014;75:429–34.CrossRefPubMedGoogle Scholar
  34. 34.
    Lee H, Kim JS, Chung EJ, Yi HA, Chung IS, Lee SR, et al. Infarction in the territory of anterior inferior cerebellar artery: spectrum of audiovestibular loss. Stroke. 2009;40:3745–51.CrossRefPubMedGoogle Scholar
  35. 35.
    Amarenco P, Hauw JJ. Cerebellar infarction in the territory of the anterior and inferior cerebellar artery. Brain. 1990;113:139–55.CrossRefPubMedGoogle Scholar
  36. 36.
    Ahn BH, Kim HA, Yi HA, Oh SY, Lee H. Abnormal cervical vestibular-evoked myogenic potential in anterior inferior cerebellar artery territory infarction: frequency, pattern, and a determinant. J Neurol Sci. 2011;307:114–9.CrossRefPubMedGoogle Scholar
  37. 37.
    Lee H. Audiovestibular loss in anterior inferior cerebellar artery territory infarction: a window to early detection? J Neurol Sci. 2012;313:153–9.CrossRefPubMedGoogle Scholar
  38. 38.
    Bodranghien F, Bastian A, Casali C, Hallett M, Louis ED, Manto M, et al. Consensus paper: revisiting the symptoms and signs of cerebellar syndrome. Cerebellum. doi 10.1007/s12311-015-0687-3
  39. 39.
    Kim JS, Lee H. Vertigo due to posterior circulation stroke. Semin Neurol. 2013;33:179–84.CrossRefPubMedGoogle Scholar
  40. 40.
    Huh YE, Koo JW, Lee H, Kim JS. Head-shaking aids in the diagnosis of acute audiovestibular loss due to anterior inferior cerebellar artery infarction. Audiol Neurootol. 2013;18:114–24.CrossRefPubMedGoogle Scholar
  41. 41.
    Lee H, Yi HA, Chung IS, Lee SR. Long-term outcome of canal paresis of a vascular cause. J Neurol Neurosurg Psychiatry. 2011;82:105–9.CrossRefPubMedGoogle Scholar
  42. 42.
    Amarenco P, Hauw JJ. Cerebellar infarction in the territory of the superior cerebellar artery: a clinicopathologic study of 33 cases. Neurology. 1990;40:1383–90.CrossRefPubMedGoogle Scholar
  43. 43.
    Kase CS, White JL, Joslyn JN, Williams JP, Mohr JP. Cerebellar infarction in the superior cerebellar artery distribution. Neurology. 1985;35:705–11.CrossRefPubMedGoogle Scholar
  44. 44.
    Lee H, Kim HA. Nystagmus in SCA territory cerebellar infarction: pattern and a possible mechanism. J Neurol Neurosurg Psychiatry. 2013;84:446–51.CrossRefPubMedGoogle Scholar
  45. 45.
    Kim HA, Yi HA, Lee H. Failure of fixation suppression of spontaneous nystagmus in cerebellar infarction: frequency, pattern, and a possible structure. Cerebellum. doi 10.1007/s12311-015-0688-2.
  46. 46.
    Mazzoni A. Internal auditory canal. Arterial relations at the porus acusticus. Ann Otol Rhinol Laryngol. 1969;78:797–814.CrossRefPubMedGoogle Scholar
  47. 47.
    Kim HN, Kim YH, Park IY, Kim GR, Chung IH. Variability of the surgical anatomy of the neurovascular complex of the cerebellopontine angle. Ann Otol Rhinol Laryngol. 1990;99:288–96.CrossRefPubMedGoogle Scholar
  48. 48.
    Kim JS, Lee H. Inner ear dysfunction due to vertebrobasilar ischemic stroke. Semin Neurol. 2009;29:534–40.CrossRefPubMedGoogle Scholar
  49. 49.
    Matsushita K, Naritomi H, Kazui S, Watanabe Y, Okazaki H, Kuriyama Y, et al. Infarction in the anterior inferior cerebellar artery territory: magnetic resonance imaging and auditory brain stem responses. Cerebrovasc Dis. 1993;3:206–12.CrossRefGoogle Scholar
  50. 50.
    Oas JG, Baloh RW. Vertigo and the anterior inferior cerebellar artery syndrome. Neurology. 1992;42:2274–9.CrossRefPubMedGoogle Scholar
  51. 51.
    Kim HA, Lee BC, Hong JH, Yeo CK, Yi HA, Lee H. Long-term prognosis for hearing recovery in stroke patients presenting vertigo and acute hearing loss. J Neurol Sci. 2014;339:176–82.CrossRefPubMedGoogle Scholar
  52. 52.
    Sunderland S. The arterial relations of the internal auditory meatus. Brain. 1945;68:23–7.CrossRefGoogle Scholar
  53. 53.
    Lee H. Sudden deafness related to posterior circulation infarction in the territory of the nonanterior inferior cerebellar artery: frequency, origin, and vascular topographical pattern. Eur Neurol. 2008;59:302–6.CrossRefPubMedGoogle Scholar
  54. 54.
    Simmons Z, Biller J, Adams HP, Dunn V, Jacoby CG. Cerebellar infarction: comparison of computed tomography and magnetic resonance imaging. Ann Neurol. 1986;19:291–3.CrossRefPubMedGoogle Scholar
  55. 55.
    Tarnutzer AA, Berkowitz AL, Robinson KA, Hsieh YH, Newman-Toker DE. Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome. CMAJ. 2011;183:E571–592.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  1. 1.Department of Neurology, School of MedicineKeimyung UniversityDaeguRepublic of Korea
  2. 2.Brain Research Institute, School of MedicineKeimyung UniversityDaeguRepublic of Korea

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