Visual Diagnosis: Acute-Onset Headache, Vertigo, and Torsional Nystagmus in a 13-year-old Boy

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.

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 …