Making the diagnosis

Differential diagnosis

The duration and the hearing do most of the sorting. But one mimic must never be missed: a posterior-circulation stroke can present as a textbook acute vestibular syndrome.

The stroke problem

Trainee

In the acute vestibular syndrome, around a quarter of cases are central — usually posterior-circulation stroke.1 A central HINTS pattern (normal head impulse, direction-changing or vertical nystagmus, or a skew), other brainstem/cerebellar signs, or vascular risk factors shift the diagnosis decisively away from neuritis.

Neuritis against its mimics

Vestibular neuritis is held as the reference row; tap a mimic to surface the single feature that most reliably separates it.

ConditionTypical durationHearing
Vestibular neuritisreferenceSingle attack, daysNormal (spared)
Acute, sustainedUsually normal (lost in AICA territory)
Single attack, daysAcute hearing loss + tinnitus
Recurrent, 20 min – 12 hFluctuating low-frequency loss
Seconds, positionalNormal
Recurrent, 5 min – 72 hSpared

Tap a mimic to reveal the key discriminator.

Red flags — when to image

Image and seek urgent assessment when any of these are present: a normal head-impulse test with continuous vertigo, direction-changing or vertical nystagmus, a skew deviation, new hearing loss (HINTS+), inability to stand or walk unaided, or any other focal neurological sign. Recurrent spells rather than one prolonged attack point instead to Ménière’s disease, vestibular migraine or BPPV; the emergency chapter places all of this in a triage pathway.

Key points

  • The must-not-miss mimic is posterior-circulation stroke, which can look exactly like neuritis.
  • A central HINTS pattern, new hearing loss (HINTS+) or focal signs mandate imaging.
  • Labyrinthitis = neuritis + acute hearing loss; look for an ear or meningitis source.
  • Recurrent spells (not one prolonged attack) point to Ménière’s, vestibular migraine or BPPV.