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- Helen Wu, MS*
- Amanda Weber, DO†
- Asri Yuliati, MD†
- *MD/PhD Program, and
- †Department of Neurology, Children’s Hospital of Michigan, Detroit Medical Center, Wayne State University School of Medicine, Detroit, MI
AUTHOR DISCLOSURE
Ms Wu and Drs Weber and Yuliati have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.
Presentation
A 13-year-old boy presents to the emergency department with a 4-day history of new-onset severe bifrontal aching headache with associated nausea, vomiting, photophobia, phonophobia, and vertigo. He had been evaluated at another institution twice in the preceding 4 days for the same complaint, and he failed outpatient management with naproxen and meclizine. His previous medical history is unremarkable. He denies drug use. The emergency department administers a migraine cocktail consisting of ketorolac, diphenhydramine, and prochlorperazine, which results in significant pain improvement, but the vertigo persists.
On physical examination, vital signs and results of pulmonary, cardiac, gastrointestinal, and skin examinations are normal. He is awake, alert, and oriented. His neurologic examination is remarkable for a rightward head tilt, torsional nystagmus (Video), dysmetria with finger-to-nose evaluation greater on the left, and difficulty with tandem gait. He is able to ambulate independently. Reflexes and sensory examination findings are normal. Due to nystagmus, the funduscopic examination cannot be completed. Basic laboratory electrolyte panel and complete blood cell count are noncontributory. Magnetic resonance imaging (MRI) is ordered emergently and reveals the diagnosis.
Video. The patient demonstrated subtle rotational nystagmus with leftward fast component.
Diagnosis
Based on his physical examination and laboratory findings, the differential diagnosis for the patient’s complaints includes a brainstem or cerebellar stroke, mass, vascular …
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