Cryptogenic Posterior Circulation Stroke in a Young Adult - Utility of the HiNTs exam in the Emergency Department

Authors

Natalie ChenFollow

Abstract

CASE REPORT: The authors report a case in which a 23- year-old male with a history of migraines presents to the emergency department after waking up with a headache, vertigo, tinnitus, nausea and vomiting, six hours prior to arrival. Upon initial emergency department triage assessment, the patient passed the Fast Arm Speech Test (FAST) screening exam and a hyperacute stroke protocol was not activated. The complete neurologic assessment was unremarkable aside from an ataxic gait and a positive Romberg’s sign. However, Head-Impulse-Nystagmus-Test of Skew (HiNTs) exam revealed findings consistent with a cerebellar lesion. Subsequent emergency department imaging via head and neck computed tomography angiography (CTA) revealed a left superior cerebellar artery occlusion with associated left superior cerebellar territory infarct and a tiny right cerebellar infarct. The patient was not a candidate for tissue plasminogen activator (tPA) or mechanical thrombectomy and was admitted to the neurology stroke unit.

Posterior circulation (vertebrobasilar) strokes are a less common cause of acute strokes, making up twenty percent of all cerebrovascular ischemic events¹. However, posterior circulation strokes are three times more likely to be missed due to atypical symptoms² and have greater mortality and morbidity when misdiagnosed³. Furthermore, although early-onset strokes are uncommon⁴, typically documented causalities such as vasculopathies, cardiac defects, and hypercoagulable states are not found in up to fifty percent of these cases⁵. This case report serves as a reminder of the atypical presentation in posterior circulation stroke presentations as well as the cryptogenic nature of early-onset strokes and demonstrates the utility of the HiNTs exam in distinguishing cerebellar versus peripheral lesions in the Emergency Department.

Recommended Citation

Chen, Natalie (2020) "Cryptogenic Posterior Circulation Stroke in a Young Adult - Utility of the HiNTs exam in the Emergency Department," Loma Linda University Student Journal: Vol. 4: Iss. 1, Article 4.
Available at: https://scholarsrepository.llu.edu/llu-student-journal/vol4/iss1/4