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8th August 2024
Vertigo
It may be difficult to discern a posterior circulation stroke from its differentials. For persistent vertigo in the absence of other neurology, the HINTS (head impulse, nystagmus, test of skew) examination can be used to differentiate central from peripheral causes. However, often an MRI scan is required. Key differentials and features include:
| Differential | Key points |
|---|---|
| Stroke or TIA | Constant symptoms, bidirectional nystagmus, positive skew, normal head impulse, other localising neurology, vascular risk factors. |
| Benign paroxysmal positional vertigo (BPPV) | Recurrent episodes lasting a few seconds triggered by rotation of the head. Diagnosis is with the Dix-Hallpike manoeuvre; treatment with the Epley manoeuvre. |
| Ménière disease | Episodes of vertigo lasting 20 minutes to hours. Also, hearing loss, tinnitus and aural fullness. |
| Basilar migraine | Positive symptoms (fortification spectra, paraesthesia), spread from one area to another and headache. Likely history of migraine. |
| Labyrinthine disorders | Positive head impulse, tinnitus, unidirectional horizontal ± torsional nystagmus; recent viral illness. |
| Acoustic neuroma | Unilateral hearing loss, false localising signs, absent corneal reflex. If bilateral, consider type 2 neurofibromatosis.. |
| Ototoxicity | Recent treatment with loop diuretics, aminoglycosides or cisplatin. |
| Motion sickness, alcohol intoxication, trauma | Cause should be evident from history. |
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