← Diagnosis and Management Guides
Vertigo / Acute Vestibular Syndrome
Key considerations: Posterior circulation stroke (cerebellar/brainstem), Vertebral artery dissection, Cerebellar hemorrhage
Cannot miss
- Posterior circulation stroke (cerebellar/brainstem)
- Vertebral artery dissection
- Cerebellar hemorrhage
Likely diagnoses
- BPPV
- Vestibular neuritis/labyrinthitis
- Meniere disease
- Vestibular migraine
Red flags
- HINTS exam suggesting central cause
- Acute onset with vascular risk factors
- Inability to walk
- Focal neurological deficits
- Severe headache
- Hearing loss (acute)
Workup
- history: Episodic vs continuous; Triggered by position vs spontaneous; Duration of episodes; Hearing changes, tinnitus; Headache, neck pain; exam: HINTS exam (Head Impulse, Nystagmus, Test of Skew); Dix-Hallpike maneuver; Gait assessment; Cranial nerves; Cerebellar exam (finger-nose, heel-shin, rapid alternating); labs: Glucose; Consider CBC, BMP if systemic cause suspected; imaging: MRI with DWI if central cause suspected (CT misses 50% of posterior fossa strokes in first 24h); CTA if dissection suspected; bedside: HINTS exam (most important bedside test); Dix-Hallpike for BPPV
Management
- immediate: Assess for central vs peripheral cause using HINTS; IV access if concern for stroke; Antiemetics: ondansetron 4mg IV; general: BPPV: Epley maneuver (no medications needed); Vestibular neuritis: steroids (prednisone), short course vestibular suppressants; Avoid long-term vestibular suppressants (delay compensation); specific: diagnosis: BPPV; steps: Epley maneuver (posterior canal); Discharge with home exercises; No vestibular suppressants needed; diagnosis: Vestibular Neuritis; steps: Short-term vestibular suppressants (meclizine 25mg, diazepam 2mg); Prednisone taper; Vestibular rehabilitation referral; diagnosis: Central Vertigo (Stroke); steps: Stroke protocol — CT/CTA/MRI; Neurology consult STAT; tPA/thrombectomy if applicable
Disposition
- admit: Central vertigo/stroke; Unable to ambulate safely; Intractable vomiting with dehydration; discharge: BPPV after successful Epley; Vestibular neuritis with adequate PO intake and safe ambulation; consults: Neurology if central cause suspected; ENT for recurrent peripheral vertigo
Clinical pearls
- HINTS exam is MORE sensitive than MRI in first 24h for detecting posterior circulation stroke
- Central: no corrective saccade on head impulse, direction-changing nystagmus, skew deviation
- Peripheral: positive head impulse (corrective saccade), unidirectional nystagmus, no skew
- CT is INADEQUATE for posterior fossa — MRI with DWI is needed if central cause suspected
Source and review
- Kattah et al., Stroke 2009 (HINTS); Newman-Toker et al., Neurol Clin 2015. Last reviewed: 2024-11-01