Case 02 of 8 · Foundation · Vestibular neuritis

Sudden vertigo in a healthy 30-year-old

A previously well 30-year-old with three days of constant vertigo and unsteadiness.

CASE VIGNETTE

A 30-year-old previously well woman presents with three days of constant spinning vertigo, severe nausea, and inability to walk without help. She describes the world spinning to the left, worse with any head movement, partly improved by lying still with the head propped up.

She has no hearing change, no tinnitus, no headache, no neurological symptoms elsewhere. Three weeks earlier she had a self-limiting viral upper respiratory illness.

On examination there is a coarse left-beating horizontal-torsional nystagmus with the fast phase to the left in primary gaze, worse with rightward gaze (Alexander's law). The nystagmus is markedly suppressed by visual fixation. Bedside head-impulse testing shows clear catch-up saccades on rightward thrusts and normal responses on leftward thrusts. There is no skew on alternate cover test. Hearing is grossly normal. Romberg falls to the right. The remainder of the cranial nerve and limb examination is normal.

Vestibular neuritis is a vestibular nerve disease, not a cochlear one. Hearing is preserved by definition; presence of acute SNHL alongside acute vertigo would push the diagnosis toward labyrinthitis or labyrinthine infarction.

DVA SIGNATUREModerate

Acute right peripheral vestibular loss (neuritis)

DVA loss: Marked asymmetric loss: 0.4 logMAR on rightward thrusts, ~0.05 logMAR on leftward
Laterality: Unilateral right
Asymmetry: Highly asymmetric — diagnostic of acute unilateral peripheral disease
Corroborating tests: Bedside HIT abnormal on right · unidirectional fixation-suppressed nystagmus · negative HINTS for central

Key signature: Directional DVA asymmetry is the canonical signature of acute unilateral peripheral vestibular loss. Head motion towards the affected side probes the impaired canal.

Test-battery findings

DVA — rightward thrust	0.4 logMAR loss (severely abnormal)
DVA — leftward thrust	~0.05 logMAR loss (within normal limits)
Spontaneous nystagmus	Left-beating horizontal-torsional, fixation-suppressed
Bedside HIT	Catch-up saccades on rightward thrusts only
Test of skew	Negative
Hearing	Normal

Question

Which feature most strongly supports a diagnosis of acute right vestibular neuritis rather than a posterior circulation stroke?

References

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Acute right peripheral vestibular loss (neuritis)

Test-battery findings

Question

Further reading

References