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I have a patient who has recurrent TIA/RINDS/CVAs and in the past suffered what seems to be a stroke involving brainstem balance centers. She now suffers daily episodes of imbalance that are not relieved by any medication I have used to date (cinnarizine). These episodes are highly incapacitating. She does seem to have some overriding effect from oculovestibular pathways, but these are not sufficient to allow for a normal lifestyle. In the interim, she is well, but complains of a constant lightheaded or "floating" feeling. I have suggested occupational therapy to enhance oculovestibular suppression. Can you suggest any other pharmacologic intervention?
Dr. Sergio Diez Alvarez
This is certainly a difficult issue, because there is no specific drug for such symptoms and vestibular physiotherapy will probably not be extremely effective in this instance. First, I would use magnetic resonance angiography to make sure that there is no major vascular disease in the vertebrobasilar arteries (basilar stenosis or intracranial bilateral vertebral artery disease). Rheologic disturbances (for example, high hematocrit) should also be ruled out. Then, I would reassure the patient that there is no severe disease and that she will experience some spontaneous improvement, perhaps with physiotherapy. Very small doses of clonazepam (max 0.5 mg twice a day) could be helpful, if they do not induce somnolence.
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