Brief Answer:
I think it's up to the discretion of the physician

Detailed Answer:
Good morning. My name is Dr. Dariush Saghafi and I am a neurologist from the XXXXXXX OH region. I see you are from the DC area. Greetings from up North....GO BROWNS!

At any rate, your question if I understand it correctly is to try and determine whether a "ministroke" from 25 years ago which left your wife perfectly INTACT neurologically which may be suspected as having caused an episode of recent onset VERTIGO could be done as an outpatient?

I see the terms CT and MRI but I'm not clear what you're asking or telling me with those terms as they appear. Are you telling me that those are the tests they intend on doing or are you asking which of those 2 imaging studies would be best to do on your wife to evaluate her?

Your question is a little tricky to answer because the best answer should be from the person actually examining your wife and evaluating them. If you provide with me with a little more context then, I may be of more use.

For example, if I were the on duty neurologist for ER call and a patient came in complaining of sudden vertigo out of nowhere and this were the very first time this were happening and let's also assume that it started several hours ago and is not really letting up...which would explain why the patient took the time and made the effort to travel to the ER then, I would be concerned about that patient...without knowing anything else about them. If I were then, told by the nurse that this patient had a TIA (ministroke) 25 years ago with no residual effects (because in fact by definition that's how a TIA has to behave for it to be called TIA) and furthermore, I could get a CT of her head in the ER and show that she had no bleed in the brain, no evidence of a stroke, and not other evidence on neurological examination of a specific deficit in the brain causing the vertigo....then, after doing the rest of the lab work, EKG, urine, and checking her medications I would likely feel more comfortable releasing her from the ER with instructions and trying to make a diagnosis of sort but any further neurological workup could be done as an outpatient.

On the other hand if that same patient came in with severe vertigo of hours duration that suddenly came on with a terrible headache, nausea, vomiting, loss of hearing or buzzing in the ear that is loud and not going away, and then, on top the patient had a history of TIA in the past (even if it didn't cause damage) then, that damage is spending the night at least (even if the CT of the head is clean) to get more workup for the condition and in fact, I as the neurologist would start moving that evening to get everything completed including the MRI and so forth....but the point is that in that case I would not allow the patient to leave unless they fill out an AMA (Against Medical Advice) form.

So you see vertigo, mild, persistent but without evidence of brain based origin or disease can be handled as an outpatient whereas signs of brainstem involvement (nausea/vomiting) or cerebellar involvement (severe and sudden worst headache of their life) and even difficulty swallowing perhaps with some speech difficulty....that person ain't leaving until at least the next 24-48 hrs. and they are getting shifted to the floor right away with vigilance...I may even transfer the patient to the ICU depending on how severe symptoms are in them.

The idea of keeping a patient with signs or symptoms of TIA or stroke in the hospital is because it helps expedites the tests more and in case there is an emergency (which can happen at any time) the patient is right there at arm's length from TPA or whatever clot buster may be at hand to get rapid control on a sudden onset stroke or what have you. The idea of sending the patient home is that the physician is so convinced that the patient does not have symptoms of potential stroke that they have no longer with the patient being as far away as 30-60 min. from the hospital which puts them way behind any 8-ball when it comes to working them up or being close to them in an emergency situation.

We also teach our residents that it is preferable to overcall things when it comes to strokes rather than undercall because there is nothing we have yet that can absolutely reverse dead brain tissue once the clock has ticked off the time to have intervened on and "destroked" them so to speak.

If any of the information I've asked or provided has been useful to further your understanding or give you ideas as to which direction to turn next and you'd like to CLOSE THIS QUERY then, could you do me a favor and leave some brief feedback with a STAR RATING for the quality of the response?

Alternatively, we could continue this conversation and you may upload information if available such as lab tests, etc. and I would be happy to review them.

Please feel free to contact me at any time to ask more questions about this or any other topic you would like by using the following link:

http://doctor.healthcaremagic.com/Funnel?page=askDoctorDirectly&docId=68474

This query required 24 minutes of physician specific time to review, research, and compile the final draft for envoy.

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Brief Answer:
Thank you for additional information

Detailed Answer:
Good morning. I can understand their concern for her condition on the following basis. It is true and there are literature supports for the following statement that an episode of sudden of vertigo without any other neurological deficit (i.e. weakness in a limb, alteration of speech or consciousness, visual disturbance, severe headache, etc) can be the reflection of a loss of circulation to what is referred to as the VERTEBROBASILAR region of the brain. This is the blood supply in the back portion of the head that climbs up from the spinal cord region, joins in the brainstem region as one large blood vessel called the Basilar artery and then, divides into what are called the Posterior Cerebral Arteries. Along the way there are feeders to other parts of the brainstem and the cerebellum.

When there is a compromise to this circulation either by way of blood clot, low blood pressure, dehydration, or whatever the cause it is possible (although unusual) that the patient complain of an isolated sensation of vertigo and virtually nothing else...no nausea, no vomiting, etc. The duration that such a symptom could last depends upon the length of time that the blood flow is "down." Having said that, it makes sense that if the vertigo were being caused by a lack of blood flow to some critical component of the brainstem or its associated connections into the cerebellum etc. that the longer the low flow state existed the more likely the patient would be to exhibit other more characteristic symptoms of brainstem compromise (i.e. nausea, vomiting, alterations in level of alertness, etc.).

However, if the episode were brief or fleeting as seems to be the case here and the low flow state spontaneously corrects itself the symptom would subside almost as quickly as it came on and there'd be no residual symptoms.

Of course, this is all assuming that her vertigo originated and was caused by a blockage in that circulation to begin with. If the episode of vertigo that came on came on for some other reason (and there are lots of other potential causes for vertigo) then, the foregoing discussion is irrelevant and the cause of the vertigo needs to be identified and treated without any regard to strokes, TIA's, blood clots, etc. etc.

I don't know what it was that caused either the ER physician or attending neurologist who is likely the one suggesting the inhouse workup to suggest she stay for additional testing but that would be a discussion you'd have to have with them. However, the argument I've presented to you is one that some would consider enough of a risk for potential stroke that they would feel uncomfortable releasing her...and it may have been on the basis of the history of the TIA from 25 years ago. Again, you'd have to check in with the doctors taking care of her to find out what their rationale was for recommending an inhouse workup.

CT scans are terribly INSENSITIVE for vascular processes in the back part of the brain unless they are large.

TIA'S by definition HAVE ZERO IMPACT neurologically on any part of the brain over any length of time since they are transient attacks which truly must pass the imaging rigors of MRI using different weighting procedures that can tell whether damage to brain tissue occurred or not. That particular knowledge and technology for imaging didn't really exist 25 years ago so what was called a TIA back then, may actually not be called a TIA today by the new standards of imaging and the time limits we use in determining at what point we make the call of actual TISSUE DAMAGE...even if the person doesn't manifest anything grossly on examination.

And so by that argument an MRI may or may not show the effects of damage to tissue over time if it met the minimum criteria to be called stroke but did not cause enough damage to be detected clinically or did not cause any more damage to an area of tissue greater than about 1 mm. in circumferential area since that is about the smallest level of resolution that MR's have to detect abnormalities.

Bottom line is this the question as to when a TIA should be worked up or not in a hospital is contingent upon:

1. The patient having suffered a TIA. In this case, the isolated symptom of vertigo in a 63 year old woman with a history of previous TIA was the red flag and as explained above there is justification for the concern (unless it can be adequantely show that her vertigo was clearly due to NON-central type of phenomenon...and that would entirely depend upon what the neurologist or ER doc found upon examining her).

2. The risk of doing a workup outside the hospital should be weighed against the risk of suffering a full blown STROKE according to the following statistics which are the most current we have:

Up to 35-40% of all people who have experienced a TIA will go on to have an actual stroke. Most studies show that about 48% of all strokes occur within the first 48 hrs after a TIA.

In fact:

Within two days after a TIA, 5 percent of people will have a stroke. Within 10 days after a TIA approximately 8% will go on to have a stroke. Within three months after a TIA, 10 to 15 percent of people will have had a stroke. And that means RELATED to the initial TIA.

Think of TIA's then, as minor seismic tremors in the body which occur just before the roof blows off the volcano. But the problem is who is to say after the initial tremors (which may not even cause any real damage) WHEN the volcano is going to blow? It could be the next day, the next month, or not even in our lifetime....but with a stroke as a risk for outcome....we know those numbers fairly accurately and so I think it is wise to over-call these things sometimes and save on the consequence since we know the probabilities.

Again, I think the doctors in this case were playing things more cautiously and felt that the inconvenience of 2 days in a hospital bed was worth possibly saving your wife from a stroke. If they did find something that justified their concern then, you'd be forever grateful that they convinced her to stay....am I correct? If they don't find anything substantial (and from what you're saying this very well may be the case) then, would you be as in agreement with their approach of precaution and concern? Knowing what I know as a neurologist my answer would be YES if this were applied to my wife...but again, I agree that all this is predicated on the actual diagnosis of what CAUSED the vertigo to begin with.

The only people who can answer THAT question are the doctors who examined your wife.

All the best.

If any of the information I've asked or provided has been useful to further your understanding or give you ideas as to which direction to turn next and you'd like to CLOSE THIS QUERY then, could you do me a favor and leave some brief feedback with a STAR RATING for the quality of the response?

Please feel free to contact me at any time to ask more questions about this or any other topic you would like by using the following link:

bit.ly/drdariushsaghafi

This query required 45 minutes of physician specific time to review, research, and compile the final draft for envoy.

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