Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome
Tarnutser et al. CMAJ 2011; 183(9): E571-E593
• The most common causes of acute vestibular syndrome are vestibular neuritis (often called labyrinthitis) and ischemic stroke in the brainstem or cerebellum.
• Vertebrobasilar ischemic stroke may closely mimic peripheral vestibular disorders, with obvious focal neurologic signs absent in more than half of people presenting with acute vestibular syndrome due to stroke.
• Computed tomography has poor sensitivity in acute stroke, and diffusion-weighted magnetic resonance imaging (MRI) misses up to one in five strokes in the posterior fossa in the first 24–48 hours.
• Expert opinion suggests a combination of focused history and physical examination as the initial approach to evaluating whether acute vestibular syndrome is due to stroke.
• A three-component bedside oculomotor examination — HINTS (horizontal head impulse test, nystagmus and test of skew) — identifies stroke with high sensitivity and specificity in patients with acute vestibular syndrome and rules out stroke more effectively than early diffusion-weighted MRI.