What is the most likely diagnosis in a patient with abrupt severe headache, vertigo, nystagmus, sensory loss, and facial weakness on one side?

What is the most likely diagnosis in a patient with abrupt severe headache, vertigo, nystagmus, sensory loss, and facial weakness on one side?

• A. Cervical artery dissection
• B. Cerebellar hemorrhage
• C. Internal auditory artery occlusion
• D. Lacunar infarction

Answer: (B)

A sudden, severe headache with vertigo, nystagmus, sensory loss, and unilateral facial weakness points to a bleed in the posterior fossa, most likely a cerebellar hemorrhage. Bleeding in the cerebellum often presents with an abrupt onset headache and dizziness due to pressure effects on surrounding structures. As the hematoma expands, it can involve the brainstem and cranial nerve pathways, producing ipsilateral facial weakness and sensory changes, along with ataxia, vertigo, and nystagmus from disruption of cerebellar and vestibular circuits. This combination makes a cerebellar hemorrhage the most likely diagnosis in this vignette. Cervical artery dissection can cause posterior circulation stroke with similar symptoms, but it typically presents with neck pain and often lacks the abrupt thunderclap headache. Internal auditory artery occlusion would mainly cause sudden hearing loss with vertigo and is less likely to produce facial weakness or broader sensory loss. Lacunar infarction causes small-vessel strokes that usually produce pure motor or pure sensory deficits without the headache and cerebellar/cranial-nerve signs seen here.

A sudden, severe headache with vertigo, nystagmus, sensory loss, and unilateral facial weakness points to a bleed in the posterior fossa, most likely a cerebellar hemorrhage. Bleeding in the cerebellum often presents with an abrupt onset headache and dizziness due to pressure effects on surrounding structures. As the hematoma expands, it can involve the brainstem and cranial nerve pathways, producing ipsilateral facial weakness and sensory changes, along with ataxia, vertigo, and nystagmus from disruption of cerebellar and vestibular circuits. This combination makes a cerebellar hemorrhage the most likely diagnosis in this vignette.

Cervical artery dissection can cause posterior circulation stroke with similar symptoms, but it typically presents with neck pain and often lacks the abrupt thunderclap headache. Internal auditory artery occlusion would mainly cause sudden hearing loss with vertigo and is less likely to produce facial weakness or broader sensory loss. Lacunar infarction causes small-vessel strokes that usually produce pure motor or pure sensory deficits without the headache and cerebellar/cranial-nerve signs seen here.