What is vestibular syndrome and what are its physical examination findings?

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Last updated: October 8, 2026 • View editorial policy

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Acute Vestibular Syndrome: Definition and Physical Examination Findings

Acute vestibular syndrome (AVS) is defined as sudden-onset, continuous vertigo lasting longer than 24 hours with associated nausea/vomiting, gait instability, nystagmus, and head-motion intolerance 1, 2.

Core Clinical Features

AVS represents a distinct clinical presentation characterized by:

  • Persistent vertigo (not episodic) lasting >24 hours
  • Nausea and vomiting that worsen with head movement
  • Continuous symptoms (distinguishing it from brief positional vertigo)
  • Gait instability and difficulty walking
  • Head-motion intolerance

The syndrome can result from either peripheral causes (most commonly vestibular neuritis) or central causes (posterior circulation stroke affecting brainstem or cerebellum). Critically, 25% of AVS cases are due to stroke, rising to 75% in high vascular risk patients, and 75-80% of stroke-related AVS cases lack focal neurologic deficits 1.

Essential Physical Examination Findings

The HINTS Examination (Head Impulse, Nystagmus, Test of Skew)

When performed by specially trained clinicians, HINTS is more sensitive than early MRI for detecting stroke (100% vs 46%) 1. However, when performed by non-experts, accuracy drops significantly 3.

1. Head Impulse Test (HIT)

  • Tests vestibulo-ocular reflex (VOR)
  • Abnormal (corrective saccade) = peripheral cause
  • Normal = suggests central cause (stroke)

2. Nystagmus Pattern

  • Unidirectional horizontal nystagmus (beats away from affected side) = peripheral
  • Direction-changing nystagmus (changes with gaze direction) = central
  • Vertical nystagmus (upbeat or downbeat) = central only
  • Gaze-evoked nystagmus = central

3. Test of Skew (Vertical Skew Deviation)

  • Alternate cover test looking for vertical misalignment
  • Presence of skew = central cause

HINTS Plus

Add hearing assessment to standard HINTS:

  • Acute hearing loss with AVS = higher stroke risk 3
  • Use finger rub test at bedside to assess hearing 3

Additional Critical Examination Elements

Gait testing:

  • Severe gait unsteadiness (inability to walk without assistance) in patients without nystagmus suggests central cause 3
  • Patients with peripheral causes can usually walk with assistance

Neurologic examination:

  • Search for focal deficits (dysarthria, facial weakness, limb weakness, sensory loss)
  • Absence of focal findings does NOT exclude stroke - up to two-thirds of AVS strokes lack obvious neurologic signs 1

Common Pitfalls

  1. Relying on CT imaging: Detection rate of CNS pathology in isolated AVS is <1% on CT; CT is not appropriate 1, 3

  2. Assuming normal neurologic exam = benign: 11% of patients with acute persistent vertigo and no focal neurologic signs have acute infarct 1

  3. HINTS performed by untrained clinicians: Without specialized training, HINTS accuracy is poor and should not be relied upon 3

  4. Early MRI limitations: Standard MRI misses 54% of strokes in AVS when performed early; diffusion-weighted imaging has only 4% positivity in isolated dizziness 1

  5. Confusing AVS with episodic vertigo: Brief episodes triggered by position changes suggest BPPV, not AVS

Distinguishing Central vs Peripheral Features

Peripheral vestibular features:

  • Unidirectional horizontal nystagmus
  • Abnormal head impulse test
  • No skew deviation
  • Can walk with assistance
  • No focal neurologic signs

Central vestibular features:

  • Direction-changing or vertical nystagmus
  • Normal head impulse test
  • Skew deviation present
  • Severe gait instability
  • May have focal neurologic signs (but often absent)

The presence of ANY central feature should prompt urgent MRI evaluation 1, 3.

References

1
Guideline

acr appropriateness criteria® dizziness and ataxia: 2023 update.

Journal of the American College of Radiology, 2024

2
Research

Acute Vestibular Syndrome.

Continuum (Minneapolis, Minn.), 2021

3
Research

Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE-3): Acute dizziness and vertigo in the emergency department.

Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 2023

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.