Vomiting out of proportion to dizziness in ischemic brainstem strokes

Abstract

At the onset of ischemic strokes involving the lower brainstem, vomiting may be prominent when dizziness and other neurologic abnormalities are minimal or absent. Errors in interpretation may result in the misdiagnosis of a gastrointestinal disorder. The stroke literature does not clearly refer to this clinical point. The present note draws attention to the phenomenon both for practical diagnostic reasons and to illustrate a distinct form of vestibular vomiting.A 52-year-old hypertensive, diabetic man with a history of myocardial infarction awakened at 1 AM with nausea and vomiting. He vomited hourly until arrival a t the Emergency Department at 8 AM. He had no history of dizziness, headache, abdominal pain, or diarrhea. On examination the man was alert and afebrile; his abdomen felt normal; and his neurologic status was intact except for peripheral neuropathy. His blood pressure was 220/118 mm Hg. Blood chemistry test results were normal. Nifedipine (sublingual), promethazine, and hydralazine (intravenous) were administered. Acute gastroenteritis was suspected and the man was admitted to the Medical Service.On day 1 further vomiting occurred and the man requested medication for headache once. By 10 PM, 12 hours after admission, his blood pressure fell to 110/60 mm Hg; he became diaphoretic and reported that, momentarily, the door appeared to slant sideways and his wife, standing near the bed, looked like she was upside down. Examination within 15 minutes showed no new abnormality. Vision was chronically impaired by diabetic retinopathy treated with laser and the fundi could not be seen. The vomitus was coffee-ground and the differential diagnoses included gastrointestinal bleeding. There had been no dizziness. A CT scan of the head was normal. On day 2 nausea continued with occasional vomiting. On returning to bed after voiding, the patient was dizzy briefly, for the first time, and "the world tilted like it did last night." His blood pressure, treated vigorously, was 135/70 mm Hg. On days 3 and 4 nausea continued with occasional vomiting and, for the second time, medication was requested for headache. Hypertensive encephalopathy was considered. On day 5 hoarseness and dysphagia appeared abruptly, and in the following 12 hours a complete lateral medullary syndrome developed. The man's restlessness precluded satisfactory MRI scanning. Respiratory complications followed and cardiac arrest occurred 12 hours later. An autopsy was not performed. Thrombosis of the left vertebral artery was suspected.In the incipient stage, intractable nausea and vomiting were quite out of proportion to dizziness. Headache, neither persistent nor severe, was ascribed to hypertension. Tilted vision and upside-down vision, although infrequently reported in the literature, would probably have led a neurologist to the right diagnosis.Case 2. A 70-year-old hypertensive man, while traveling on a commercial airliner, vomited forcefully six times in 20 minutes. He sat with his eyes closed; he was pale, diaphoretic, and cold. On arrival after 2...

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