Case · Clinician · Inferior vestibular neuritis
Vertigo with normal horizontal head impulse
45-year-old man, recent flu-like illness.
Vignette
A 45-year-old man presents with 12 hours of acute vertigo. The horizontal head impulse is normal. Down-beat torsional nystagmus is present, predominantly with downward gaze, and cVEMP is absent on the right with preserved oVEMPs bilaterally.
Diagnostic question
Which interpretation is best supported?
Teaching point
A normal horizontal head impulse with central-looking nystagmus is usually a central red flag, but the VEMP pattern can localise an isolated inferior vestibular neuritis — a peripheral lesion that spares the horizontal canal afferents. HINTS is interpreted alongside the rest of the vestibular battery.
References: 11