A 63-year-old man developed a transient episode of vertigo, slurred speech, diplopia, and paresthesia. He is symptom-free now, and clinical examination is entirely normal. His past medical history is significant for hypertension and dyslipidemia. Which of the following is the most likely cause for symptoms?
First, the core concept here is transient ischemic attacks (TIAs). TIAs are temporary neurological deficits caused by focal cerebral ischemia, typically lasting less than 24 hours. They're often due to small emboli or microinfarcts, especially in patients with risk factors like hypertension and dyslipidemia.
The symptoms mentioned—vertigo, slurred speech, diplopia, paresthesia—are classic for posterior circulation TIAs. The posterior circulation involves the vertebral and basilar arteries, supplying the brainstem and cerebellum. Vertigo and diplopia suggest involvement of the vestibular system or cranial nerves. Slurred speech (dysarthria) and paresthesia point to brainstem lesions. Since the patient is now asymptomatic and the exam is normal, this fits a TIA rather than a stroke, which would have lasting deficits.
Looking at the options, the correct answer is likely TIA. Let's check the other options. Option A might be something like "Migraine with aura," but migraines usually have a different presentation, often with headache and visual disturbances. Option B could be "Multiple sclerosis," but MS typically has relapsing-remitting symptoms over time, not a single transient episode. Option C might be "Vestibular neuritis," which causes vertigo but usually without the other neurological signs. Option D could be a stroke, but since the patient is now fine, that's less likely.
Clinical pearl: TIAs are warning signs of impending stroke. Immediate evaluation with imaging (like MRI) and risk factor management are crucial. Remember that posterior circulation TIAs can present with brainstem/cerebellar symptoms without motor deficits.
**Core Concept**
This question tests the recognition of transient ischemic attack (TIA) in the posterior circulation. TIA is a temporary neurologic deficit caused by focal cerebral ischemia, often resolving within 24 hours. Posterior circulation (vertebrobasilar) TIAs commonly present with brainstem or cerebellar symptoms, including vertigo, diplopia, dysarthria, and paresthesia.
**Why the Correct Answer is Right**
The patient’s transient, resolving symptoms (vertigo, slurred speech, diplopia, paresthesia) and normal examination are classic for a posterior circulation TIA. Hypertension and dyslipidemia are major risk factors for atherosclerosis, which can cause emboli or stenosis in the vertebral/basilar system. The posterior circulation supplies the brainstem and cerebellum, where ischemia leads to ataxia, cranial nerve dysfunction (diplopia), and sensory deficits. The absence of permanent deficits confirms it is not a stroke.
**Why Each Wrong Option is Incorrect**
**Option A: Vestibular neuritis** – Causes isolated vertigo with nystagmus but lacks dysarthria, diplopia, and paresthesia.
**Option B: Migraine with brainstem aura** – May include