Dizziness is mostly considered to be a benign problem. It is a common public perception as well as thinking of most general practitioners that dizziness or vertigo arises from disorders of cervical spine. This leads to mistaken advise of getting an MRI scan of the cervical spine and then to use cervical collar for prevention of such vertigo. The purpose of this blog is to create awareness among public, as well as doctors regarding occasional serious nature of this complaint.
Here’s a case study:
A 60 year old male complained of recurrent dizziness or (chakkar as we know it in Hindi) with occasional loss of awareness, and weakness and numbness involving all four limbs. Each episode used to last for 20 minutes with spontaneous recovery. Patient consulted his physician, who prescribed him cervical collar and antivertigo treatment. After such four-five attacks over one week, patient suddenly developed difficulty in getting up and walking, this did not resolve.
When he came to us, he was looking normal on the bed. He could see, talk, eat, drink and move all four limbs. But when asked to sit or stand, he could not do it at all. The MRI of his brain confirmed a large area of damage to the cerebellum, which controls balance of the body. Angiography of brain revealed that his one vertebral artery was blocked and other vertebral was severely stenosed in the brain, resulting in poor flow to the lifeline i.e. basilar artery.
What is basilar artery? There are two vertebral arteries, which unite to form basilar artery. This basilar artery is the most important blood vessel of the brain. If flow to this vessel is interrupted, vital areas of the brain (brain-stem) and the area which controls vision (occipital lobes) and balance (cerebellum) can be damaged permanently.
The patient’s area of balance was already damaged while brainstem and vision were at risk. Further damage to occipital areas could have resulted in complete loss of vision for life and damage to brainstem could have resulted in complete loss of power in all four limbs, paralysis of muscles of swallowing, eye movements or even in coma or vegetative state (awake coma). In such a situation, the only solution is to re-establish flow in the basilar artery, which was possible only if we could open one of his vertebral arteries in the brain.
Since this is a tricky procedure, after taking high risk consent, patient was taken in cath lab and stent was put in stenosed vertebral artery. Today, the patient has started walking with support with no other deficits. Flow in the basilar artery is also normal now.
Any person who suffers from sudden onset of RESCUE symptoms is suffering from stroke, unless proved otherwise.
RESCUE stands for:
- Reduced power or paralysis of one side (Weakness/numbness of face/arm/leg)
- Eye problem (Loss of vision in one or both eyes)
- Speech problem (Difficulty in speaking)
- Confusion (Difficulty in understanding)
- Unsteadiness (Loss of balance or vertigo)
- Excruciating headache (Worst headache of life)
Anybody who complains of dizziness along with change in the level of consciousness or weakness in the limbs or visual disturbance is at high risk of having stenosis of basilar artery or reduce flow in this vessel because of severe compromise in the blood flow in both the vertebral arteries. Timely diagnosis of such disorder can be lifesaving. However, this type of stenting is not a routine procedure and requires excellent clinical skills and experience. Intracranial stenting in brain vessels is still in infancy state all over the world and there are hardly 2-3 centres in India, who have done such procedures that too in very few cases.
Dr. Arun Garg is a Senior Neurologist with primary focus on stroke. Earlier, he developed neurology services at Max Hospital, Patparganj. He has worked at Sawai Man Singh Medical College and Hospital, Jaipur, and Institute of Human Behaviour and Allied Sciences, New Delhi. He pioneered the role of thrombolysis in acute stroke in Delhi. His interest also lies in neuro-rehabilitation, occupational therapy and stroke prevention. His passion for stroke has taken him to the University of Massachusetts, Amherst (UMASS), Massachusetts, USA and he has tied up with them for stroke prevention, education, treatment, rehabilitation and the latest research.