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Day three of unstoppable vertigo

A 52-year-old man with sudden persistent vertigo. The HINTS examination is the test that decides whether to admit or discharge.

The case

A 52-year-old taxi driver presents to the emergency department with severe vertigo that began suddenly three days ago and has not let up. He cannot walk without holding onto walls. He has vomited repeatedly over the first two days and has not eaten. He is sweating, pale, and miserable in the cubicle, but otherwise alert and conversant.

He has no headache, no neck pain, no hearing loss, no tinnitus, no diplopia, and no focal weakness or numbness. He takes amlodipine for hypertension and has a 30-pack-year smoking history.

On examination, there is spontaneous left-beating horizontal-torsional nystagmus that is suppressed by visual fixation and increases when fixation is removed. Head-impulse testing reveals a clear catch-up saccade on right head impulse. Cover testing shows no skew deviation. Hearing is intact on bedside whispered voice testing.

He is unable to stand without falling toward the right, but limb coordination is preserved and gait, when supported, is broad-based but reasonable.

Question

Based on the HINTS examination findings, what is the single most likely diagnosis?

Teaching point

HINTS, performed correctly within 24 hours of symptom onset, is more sensitive than early MRI for distinguishing peripheral from central acute vestibular syndrome. The three components must all point in the same direction: a peripheral pattern requires an abnormal head impulse, unidirectional fixation-suppressed nystagmus, and no skew. Any one central feature redirects the patient to a stroke pathway, regardless of how peripheral the rest of the examination looks. Add bedside hearing (HINTS-Plus) to catch AICA strokes.

References

  1. [1]Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke 2009;40(11):3504–3510. doi:10.1161/STROKEAHA.109.551234
  2. [2]Newman-Toker DE, Kattah JC, Alvernia JE, Wang DZ. Normal head impulse test differentiates acute cerebellar strokes from vestibular neuritis. Neurology 2008;70(24 pt 2):2378–2385. doi:10.1212/01.wnl.0000314685.01433.0d
  3. [3]Strupp M, Bisdorff A, Furman J, Hornibrook J, Jahn K, Maire R, Newman-Toker D, Magnusson M. Acute unilateral vestibulopathy/vestibular neuritis: diagnostic criteria. Consensus document of the Committee for the Classification of Vestibular Disorders of the Bárány Society. Journal of Vestibular Research 2022;32(5):389–406. doi:10.3233/VES-220201
Related moduleVestibular Neuritis →