LESIONS

A Guide to Localisation in Neurology

Case 24 - Dizziness and slurred speech

Outcome

A CT head was normal. The patient started dual antiplatelet therapy and a statin. He was fit to return home given he was not disabled by this event.

An MRI the next day confirmed a lesion in the right paracentral cerebellum. This was bright on DWI and dark on ADC, confirming cytotoxic oedema – consistent with a stroke in the right SCA territory.

An ECG showed sinus rhythm. A CT angiogram was normal, with no dissection. The patient currently is awaiting an echocardiogram to look for abnormalities such as patent foramen ovale which might have caused a cardioembolic stroke. Tests for causes of young-onset stroke were unremarkable.

He completed three weeks of dual antiplatelets and remains on a single agent as monotherapy along with measures to control cholesterol and blood pressure.

Acute-onset vertigo with gait and right-sided limb ataxia and dysarthric speech, due to an ischaemic stroke affecting the upper central and right paracentral cerebellum.

1. Vertigo doesn’t easily localise – causes can be peripheral or central
2. Isolated vertigo is nearly always peripheral; vertigo with additional neurological features (particularly dysarthria, diplopia or unilateral limb abnormalities) is usually central
3. Cerebellar-type dysarthria is reported to localise to the upper paracentral cerebellar regions in the territory of the SCA

Urban et al (2003). Cerebellar speech representation. Lesion topography in dysarthria as derived from cerebellar ischaemia and functional magnetic resonance imaging. JAMA Neurology 60(7)