A 68-year-old with hypertension and diabetes presents with acute, continuous vertigo, vomiting and gait unsteadiness. Examination shows direction-changing horizontal nystagmus and, notably, a normal head impulse test. There is mild truncal ataxia but no limb dysmetria and no hearing loss.

Affected earContralateral ear

VEMP traces show no peripheral, division-selective deficit — the otolith pathways are intact, consistent with a lesion above the labyrinth.

In a patient with an acute vestibular syndrome, which combination of findings should raise the GREATEST concern for a central (e.g. cerebellar or brainstem stroke) cause?

Select an option to continue.

← All clinical cases

Affected earContralateral ear

VEMP traces show no peripheral, division-selective deficit — the otolith pathways are intact, consistent with a lesion above the labyrinth.

In a patient with an acute vestibular syndrome, which combination of findings should raise the GREATEST concern for a central (e.g. cerebellar or brainstem stroke) cause?

Select an option to continue.

← All clinical cases

Acute vertigo with a deceptively normal head impulse test

In a patient with an acute vestibular syndrome, which combination of findings should raise the GREATEST concern for a central (e.g. cerebellar or brainstem stroke) cause?

Acute vertigo with a deceptively normal head impulse test

In a patient with an acute vestibular syndrome, which combination of findings should raise the GREATEST concern for a central (e.g. cerebellar or brainstem stroke) cause?