We screened medical records of 1283 consecutive patients hospitalized with vertigo as the main complaint. Overall, 437 patients had final diagnosis of Ménierè's disease (n = 132), migraine (n = 106), orthostatic hypotension (n = 68), Coronary heart disease (n = 66) and psychiatric disorders (n = 65). All of them were excluded from the analysis. The remaining 350/846 (41.3%) and 496/846 (58.6%) patients had a definite ischemic diagnosis as transient ischemic attacks (TIAs) or stroke. Among of those stroke cases, 360 (72.5%) involved in vertebrobasilar (VB) territory and 136 (27.4%) in carotid territory. Of those VB stroke cases, 66 had recurrent isolated vertigo attack history preceding the stroke (IVA), 94 had vertigo symptom accompanying hemiplegia attack history (VAH). Detailed information was presented in study flow chart (Fig. 1).
In a comparison of vascular risk factors between IVA and VAH group, patients with VAH had higher extracranial stenosis (21.2% vs. 9.0%, P < 0.01) and ABCD2 score (3.7 ± 1.9 vs. 2.3 ± 1.5, P = 0.03). However, patients with IVA showed a higher prevalence of diabetic mellitus (40.9% vs. 29.7%, P = 0.02). Other atherothrombotic risk factors, including current smoking (21.8% vs. 26.5%), history of hyperlipidemia (31.8% vs. 34.0%), hypertension (54.5% vs. 48.9%), alcohol (15.1% vs. 13.8%), and peripheral vascular disease (6.0% vs. 8.5%) were not differ significantly between the group (Table 1).
Table 1
Patient demographics and baseline characteristics (n = 160)
| IVH (n = 66) | VAH (n = 94) | P-Value |
Male (n, %) | 30 (45.4%) | 53(56.3%) | 0.25 |
Age, Mean ± SD (years) | 65.3 ± 10.5 | 62.6 ± 11.6 | 0.32 |
Hypertension (n, %) | 36 (54.5%) | 46 (48.9%) | 0.12 |
Diabetes mellitus (n, %) | 27 (40.9%) | 28 (29.7%) | 0.02* |
Body mass index, kg/m2 | 25.9 ± 5.4 | 25.1 ± 4.9 | 0.31 |
Coronary heart disease (n, %) | 6 (9.0%) | 11 (11.7%) | 0.54 |
Extracranial stenosis (n, %) | 6 (9.0%) | 20 (21.2%) | < 0.01* |
peripheral vascular disease (n, %) | 4 (6.0%) | 8 (8.5%) | 0.67 |
Dyslipidemia (n, %) | 21 (31.8%) | 32 (34.0%) | 0.78 |
Current smoking (n, %) | 14 (21.8%) | 25 (26.5%) | 0.43 |
Alcoholism (n, %) | 10 (15.1%) | 13 (13.8%) | 0.40 |
ABCD2 score, Mean ± SD | 2.3 ± 1.5 | 3.7 ± 1.9 | 0.03* |
Score ≥ 4 (n, %) | 19 (28.7%) | 45 (47.8%) | 0.02* |
IVH: recurrent isolated vertigo attack history preceding the stroke; AVH: vertigo symptom accompanying numbness or weakness attack in face, arm or soft palate history preceding the stroke; * Statistically significant, P < 0.05 |
Comparisons were made regarding to the vertigo events occurring 30 days prior to the acute VB stroke. It showed that the episodes of vertigo attack tended to be more frequent in patients with VAH (median 3.1 vs. 5.5, p < 0.03) (Fig. 2A). In addition, although the mean interval between the first vertigo symptom occurred and subsequent VB stroke (median 6.9 vs. 8.1 days, P = 0.07) showed no differences (Fig. 2B), 53 patients (56.3%, 53/94) of VAH cohort sought medical attention after vertigo arise, which showed much less in IVA cohort (36.3%, 24/66, Fig. 2C).
Cerebral infarction location was analysis between IVA and VAH further. The posterior cerebellum was more frequently involved in IVA group (68.1% vs. 27.6%, p < 0.001). However, VAH group are more likely to be involved in lateral medullary (38.2% vs. 12.1%; P = 0.03) (Table 2). In addition, the total infarction volume in IVA tended to be larger than VAH with a median of 4.56 cm3 versus 2.32 cm3 (p = 0.02, Fig. 2D). This difference was even more noticeable for territorial infarction located in posterior cerebellum with a median of 4.84 versus 1.78 cm3. By using a receiver operating characteristic (ROC) curve, a cutoff volume of > 3.99 cm3 for infarction located in the posterior cerebellum was found to be determine IVA from VAH with specificity of 76.2% and sensitivity of 73.4%; AUC (95% CI) = 0.718 (0.615, 0.820), p = 0.002 (Fig. 3).
Table 2
Analysis of infarction location
Infarction location | IVH (n, %) | VAH (n, %) | P-Value |
Anterior cerebellum | 36 (54.5%) | 34 (36.1%) | 0.61 |
Posterior cerebellum | 45 (68.1%) | 26 (27.6%) | < 0.001* |
Medial medullary | 12 (18.1%) | 25 (26.5%) | 0.07 |
Lateral medullary | 8 (12.1%) | 36 (38.2%) | 0.03* |
Anteromedial pontine | 5 (7.5%) | 11 (11.7%) | 0.41 |
Anterolateral pontine | 6 (9.0%) | 15 (15.9%) | 0.54 |
Dorsolateral pontine | 9 (13.6%) | 12 (12.7%) | 0.79 |
Midbrain infarction | 12 (18.1%) | 10 (10.6%) | 0.50 |
IVH: recurrent isolated vertigo attack history preceding the stroke; AVH: vertigo symptom accompanying numbness or weakness attack in face, arm or soft palate history preceding the stroke; Comparison between IVH and AVH; * Statistically significant, P < 0.05 |