Case 7 — Vestibular neuritis... or stroke?
Vignette
A 71-year-old man with hypertension, type 2 diabetes, and prior smoking presents with 4 hours of severe continuous vertigo, nausea, and unsteadiness. There is left-beating spontaneous nystagmus that intensifies on left gaze and does not change direction. Bedside head impulse to the right is abnormal. Test of skew is negative. He mentions, when asked specifically, that his right ear sounds 'muffled' since the symptoms began.
Six-canal vHIT
Audiogram
What is the most likely diagnosis and the most important next step?
References
- 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;40:3504–10.
- Newman-Toker DE, Kattah JC, Alvernia JE, Wang DZ. Normal head impulse test differentiates acute cerebellar strokes from vestibular neuritis. Neurology 2008;70:2378–85.
- Newman-Toker DE, Kerber KA, Hsieh YH, Pula JH, Omron R, Saber Tehrani AS, Mantokoudis G, Hanley DF, Zee DS, Kattah JC. HINTS outperforms ABCD2 to screen for stroke in acute continuous vertigo and dizziness. Academic Emergency Medicine 2013;20:986–96.