Vestibulum — Vertigo Teaching Atlas

Step 1 of 7 · HISTORY

History

A 68-year-old man with hypertension, type 2 diabetes, and a 40 pack-year smoking history presents to the ED with severe rotational vertigo that began abruptly 6 hours ago. He has vomited multiple times. He cannot stand unassisted. The vertigo is continuous and worsens with any head motion. He denies headache, hearing change, weakness, numbness, dysarthria, or visual symptoms.

Step 2 of 7 · QUESTION

Question

Which syndrome category does this fit?

Continuous severe vertigo, nausea/vomiting, gait unsteadiness, head-motion intolerance — AVS. The critical question is now peripheral (vestibular neuritis) vs central (stroke).

Step 3 of 7 · EXAM

Bedside exam — HINTS components

You proceed with the HINTS exam. Spontaneous nystagmus is present in primary gaze, beats to the LEFT on left gaze, and reverses to beat to the RIGHT on right gaze. Head impulse test is NORMAL bilaterally (no corrective saccade). Alternate cover test reveals a 4-prism-diopter vertical refixation (skew deviation present).

What you see

Fast-phase: → right-beating horizontal · slow phase: decreasing-velocity

"Jerk nystagmus appearing only on eccentric gaze, beating in the direction of gaze, with a DECREASING-velocity slow phase (leaky integrator). Bidirectional if bilateral."

→ View full nystagmus profile

Step 4 of 7 · QUESTION

Question

How would you interpret these findings?

Direction-CHANGING nystagmus, NORMAL head impulse test, and PRESENT skew deviation are each individually 'dangerous' — and here all three are present. This pattern is highly sensitive for stroke in AVS.

Step 5 of 7 · EXAM

Truncal stability and finger-rub hearing

When you ask him to sit up unsupported he topples to the right. Finger-rub hearing is symmetric. Limb finger-to-nose shows mild dysmetria on the right.

Step 6 of 7 · QUESTION

Question

Which artery distribution is most likely?

PICA territory: lateral medulla and inferior cerebellum. Truncal ataxia, central nystagmus, and limb dysmetria without hearing loss fit. May progress to Wallenberg syndrome if more medial.

Step 7 of 7 · REVEAL

Diagnosis

PICA-territory cerebellar infarction

Teaching points

1.HINTS — when performed by a trained clinician — has sensitivity approaching 100% for posterior circulation stroke in AVS, exceeding early MRI-DWI (which has 12-20% false negatives in the first 48 hours).
2.ANY ONE dangerous finding (normal HIT, direction-changing nystagmus, or skew) is sufficient to suspect stroke.
3.Cerebellar strokes can swell and herniate over 24-72 hours — admit and monitor; neurosurgical decompression can be life-saving.
4.ABCD2 score performs poorly in this setting; do not use it to triage acutely dizzy patients.

→ Read the full clinical profile of Posterior fossa stroke (cerebellar / lateral medullary)