Stroke and vertigo

Stroke that involves the vertebrobasilar circulation can cause spontaneous vertigo (see Differential diagnosis of vertigo  for the differential diagnosis of vertigo). It is an important differential diagnosis in acute vestibular syndrome, particularly in patients with vascular risk factors. Refer the patient to hospital for immediate neurological assessment when they have:
Neurological findings may not be obvious in small strokes involving the vertebrobasilar circulation—the HINTS+ clinical assessment is more accurate than early magnetic resonance imaging. HINTS+ is an acronym for ‘Head Impulse, Nystagmus, Test of Skew plus hearing loss’. See HINTS+ test results for differentiating peripheral and central causes of vertigo  for the HINTS+ test results that are helpful when trying to differentiate stroke from peripheral causes of vertigo. Computed tomography scans are not sensitive for diagnosing posterior circulation stroke.
Table 1. HINTS+ test results for differentiating peripheral and central causes of vertigo

[NB1] [NB2]

Test

Peripheral cause of vertigo

Central cause of vertigo

head impulse

+

–

nystagmus type

unidirectional

direction-changing

test of skew (ie skew deviation)

–

+

new hearing loss [NB3]

–

+

Note:

NB1: HINTS+ is an acronym for ‘Head Impulse, Nystagmus, Test of Skew plus hearing loss’. For further information, see Newman-Toker DE, Kerber KA, Hsieh YH, Pula JH, Omron R, Saber Tehrani AS, et al. HINTS outperforms ABCD2 to screen for stroke in acute continuous vertigo and dizziness. Acad Emerg Med 2013;20(10):986-96 [URL]

NB2: Each test is not 100% specific for a peripheral or central cause.

NB3: Hearing loss is a common feature of peripheral disorders in patients with episodic vertigo. However, sudden hearing loss in acute vestibular syndrome can be a sign of an anterior inferior cerebellar infarct, due to involvement of the internal auditory artery. Hearing loss is not typical of vestibular neuritis.