Vomiting And Stroke: Is There A Link?

Vomiting is a common symptom in stroke patients, with 14.5% of stroke survivors experiencing it at the onset of a stroke. It can also be a sign of recovery, as the body tries to get rid of any toxins in the blood. In some cases, vomiting may indicate the onset of another stroke, especially if accompanied by other warning signs such as slurred speech or weakness in one arm or leg. Persistent vomiting after a stroke should be treated as a medical emergency as it can lead to dehydration and malnutrition, which can cause a rapid decline in health.

Vomiting as a predictor of stroke outcome

Vomiting is one of the most common symptoms in stroke patients. It can occur during a stroke or in the aftermath of a stroke. While occasional vomiting after a stroke may be concerning, persistent vomiting should be treated as a medical emergency. This is because vomiting can lead to dehydration and malnutrition, which can cause a rapid decline in health.

A study by Shigematsu et al. (2013) found that vomiting was observed in 14.5% of all stroke patients. The percentage of vomiting varied depending on the type of stroke: 8.7% of cerebral infarction (CI) cases, 23.7% of cerebral haemorrhage (CH) cases, and 36.8% of subarachnoid haemorrhage (SAH) cases. The study also found that the risk of death was significantly higher in patients who experienced vomiting at the onset of a stroke compared to those who did not. This suggests that vomiting should be considered an early predictor of stroke outcome.

There are several possible causes of vomiting after a stroke, including:

• Cyclic vomiting syndrome: a condition characterized by recurrent episodes of vomiting separated by symptom-free periods. It is believed to be caused by a dysfunction in the gut-brain connection.
• Side effects of medication: certain medications can cause vomiting, especially when taken on an empty stomach.
• Onset of another stroke: vomiting can be a warning sign of an impending stroke, especially with hemorrhagic strokes.
• Damage to certain areas of the brain: strokes that affect the vestibular system, such as cerebellar strokes, can cause nausea, vomiting, dizziness, and poor balance.
• Ictal vomiting: while rare, seizures can sometimes manifest as vomiting. As the likelihood of seizures increases after a stroke, vomiting may signal seizure activity.
• Vestibular disorders: when the vestibular system is impacted by a stroke, it can cause a range of issues, including nausea, vomiting, dizziness, and balance problems.

To determine the cause of vomiting after a stroke, it is important to monitor the frequency and circumstances of vomiting episodes. A correct diagnosis is critical for recovery, as each cause may require a separate treatment approach. Hospitalization is often necessary for persistent vomiting to replenish fluids and provide essential nutrients.

In summary, vomiting is a common symptom in stroke patients and can be a predictor of stroke outcome. The presence of vomiting, especially at the onset of a stroke, indicates a higher risk of mortality. Therefore, it is important to seek medical attention and work with a skilled medical team to manage vomiting after a stroke.

Post-stroke vomiting as a medical emergency

Vomiting after a stroke may indicate a medical emergency. Persistent vomiting can lead to dehydration and malnutrition, which can cause a rapid decline in health and hinder post-stroke recovery. Therefore, it is crucial to seek timely medical attention and work with a skilled medical team to determine the underlying causes and appropriate treatment.

Causes of Post-Stroke Vomiting

• Cyclic Vomiting Syndrome (CVS): Characterised by recurrent episodes of vomiting followed by symptom-free periods. It is believed to be caused by a dysfunction in the gut-brain connection.
• Side effects of medication: Certain medications can induce vomiting. It is important to check the side effects on medication labels and consult a doctor before making any changes.
• Onset of another stroke: Vomiting is a common symptom of a stroke, especially with hemorrhagic strokes. It is recommended to watch for other stroke warning signs, such as slurred speech or weakness in the limbs, and seek immediate medical attention.
• Damage to certain areas of the brain: Strokes can affect specific brain regions, such as the cerebellum, leading to severe vertigo, nausea, and vomiting, as well as balance issues.
• Ictal vomiting: Although rare, vomiting can be a manifestation of seizure activity, which has an increased likelihood of occurring after a stroke.
• Vestibular disorders: When the vestibular system is impacted by a stroke, it can cause poor balance, impaired gait, dizziness, nausea, and vomiting.

Treating Post-Stroke Vomiting

Hospitalisation is often required for persistent vomiting to replenish fluids and provide essential nutrients. Medical professionals may perform various tests to diagnose underlying conditions and determine appropriate treatments. These treatments may include:

• Medications: Depending on the cause, different types of medications can be prescribed, such as tricyclic antidepressants for CVS, anti-seizure medications for ictal vomiting, and pharmacological treatments for vestibular dysfunction and vertigo.
• Adjusting problematic medications: If vomiting is a side effect of a particular medication, it may be substituted for a more tolerable alternative.
• Vestibular rehabilitation: This type of therapy involves exercises designed to retrain the brain and body to regulate the sense of equilibrium, helping to reduce nausea and vomiting caused by vestibular dysfunction.
• Alternative remedies: While there is limited evidence, some doctors may cautiously recommend acupuncture and herbal supplements as potential adjunct treatments.

Vestibular disorders and their impact on balance

Vestibular disorders occur when a disease, condition, or injury interferes with your body's balance system. The vestibular system is a link between your inner ear and your brain that helps you maintain your balance when you walk or get out of bed. Dizziness and trouble with balance are the most common symptoms of vestibular disorders, but they can also cause hearing and vision problems.

Common Vestibular Disorders

Benign Paroxysmal Positional Vertigo (BPPV)

Benign paroxysmal positional vertigo (BPPV) is the most common vestibular disorder. It occurs when tiny calcium crystals in one part of your ear move into an area where they don't belong, causing your inner ear to signal to your brain that you're moving when you're not. BPPV can be treated through a series of head movements guided by a doctor to return the crystals to their correct position.

Labyrinthitis

Labyrinthitis is an inflammation of a fragile structure deep inside the ear called the labyrinth. This disorder affects not just balance and hearing but can also cause ear pain, pressure, pus or fluid discharge from the ear, nausea, and a high fever. Labyrinthitis can be treated with antibiotics if it is caused by a bacterial infection. Steroids may also be prescribed to reduce inflammation, and antiemetics can help with vomiting and dizziness.

Vestibular Neuritis

Vestibular neuritis is caused by a viral infection elsewhere in the body, such as chickenpox or measles, which affects the nerve that sends sound and balance information from the inner ear to the brain. Common symptoms include sudden dizziness, nausea, vomiting, and difficulty walking. Treatment for vestibular neuritis typically involves medication to eliminate the underlying virus.

Perilymphatic Fistula (PLF)

Perilymphatic fistula (PLF) is a tear or defect between the middle ear and the fluid-filled inner ear, leading to dizziness and possible hearing loss. PLF can be congenital or caused by barotrauma (increased pressure in the ear), head trauma, or heavy lifting. Surgery is often recommended to repair perilymph fistulas by plugging the openings or tears with tissue from the outer ear.

Impact on Balance

Vestibular disorders can significantly impact an individual's balance and coordination, leading to feelings of dizziness, vertigo, and unsteadiness. These symptoms can interfere with daily activities, such as walking, driving, or even just getting out of bed. In some cases, vestibular disorders may also cause blurred vision, nausea, and hearing loss, further complicating the ability to maintain balance.

Treatment for vestibular disorders aims to address the underlying cause and may include medication, rehabilitation, lifestyle changes, or surgery. Vestibular rehabilitation, for example, involves specialized exercises to help retrain the brain and body to regulate the sense of balance and equilibrium.

Cyclic vomiting syndrome and the gut-brain connection

Cyclic vomiting syndrome (CVS) is a condition characterised by recurrent episodes of vomiting interspersed with periods of normal health. It is considered a central nervous system disorder and a brain-gut disorder. The exact cause of CVS is not yet known, but it is believed to be related to a dysfunction in the gut-brain connection.

Overlap with Migraines

CVS has been found to have a significant overlap with abdominal migraines and migraine headaches. Some individuals with CVS go on to develop abdominal migraines and migraine headaches later in life. There is also a subset of people who experience all three conditions, and some may experience two or three of them simultaneously. The overlap suggests a clear relationship between CVS and migraines, and treatments for CVS often involve using anti-migraine and anti-vomiting approaches.

Symptoms

In addition to relentless vomiting, individuals with CVS typically experience pallor (87%), lethargy (91%), anorexia (74%), nausea (72%), and abdominal pain (80%). The vomiting episodes can be extremely frequent, occurring on average every 10 minutes, which can lead to dehydration and missed school or work.

Treatment

Currently, there are no FDA-approved drugs specifically for CVS. Treatment approaches are often borrowed from neurology colleagues, including the use of anti-migraine medications and antiemetics. Multidisciplinary programs that involve professionals such as neurologists, psychologists, and nurses are beneficial for addressing the various aspects of the condition, such as anxiety and lifestyle issues.

Onset of another stroke

While vomiting is not a common symptom of a stroke, it can be considered a warning sign of an oncoming stroke. If you are experiencing persistent vomiting, it is important to seek immediate medical attention as it could be a medical emergency.

There are several warning signs that could indicate the onset of another stroke. These include:

• Slurred speech: If you are a stroke survivor who deals with slurred speech and you suddenly have problems finding words, this could be a warning sign of a stroke in a different part of the brain.
• Weakness: If you experience one-sided weakness and suddenly become weak in another part of your body, it could be a sign of another stroke. Any weakness that worsens over time can also signal a problem.
• Task difficulties: If you suddenly can't perform a task that was previously easy for you, it is important to get checked out by a medical professional.
• Numbness: Numbness or weakness on one side of the face, arm, or leg is a common symptom of a stroke.
• Confusion: Confusion, trouble speaking, or understanding speech can be a sign of a stroke.
• Vision problems: Trouble seeing in one or both eyes, blurred vision, or double vision can be a warning sign of a stroke.
• Dizziness: Dizziness, loss of balance, or coordination issues can be indicative of a stroke.
• Severe headache: A severe headache with no known cause can be a warning sign of a stroke.

If you or someone you know is experiencing any of these symptoms, it is important to call 911 immediately. Stroke is a medical emergency, and early treatment can increase survival rates and improve recovery outcomes. It is also crucial to follow your doctor's orders, take medications correctly, and make necessary lifestyle changes to reduce the risk of having another stroke.

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