What is the initial approach to managing a patient with vertigo and a positive Romberg test?

Management of Vertigo with Positive Romberg Test

A positive Romberg test in a patient with vertigo indicates proprioceptive or posterior column dysfunction rather than typical vestibular pathology, and requires immediate evaluation for central nervous system causes including posterior circulation stroke, cerebellar lesions, or spinal cord pathology.

Understanding the Clinical Significance

A positive Romberg test is not characteristic of typical peripheral vestibular disorders like BPPV or vestibular neuritis. 1, 2 This finding suggests:

• Proprioceptive pathway dysfunction (posterior columns of spinal cord)
• Cerebellar pathology
• Central vestibular pathway involvement (brainstem)

The combination of vertigo with a positive Romberg test should raise immediate concern for central causes, as peripheral vestibular disorders typically do not produce a positive Romberg. 2

Initial Clinical Assessment

Critical History Elements

Determine the timing and triggers of vertigo to categorize the presentation: 3

• Acute vestibular syndrome (AVS): Sudden onset, persistent vertigo lasting days with nausea/vomiting, gait instability, and head-motion intolerance 4
• Episodic vertigo: Brief episodes triggered by position changes 3
• Associated symptoms: Headache, diplopia, dysarthria, dysphagia, weakness, numbness, or ataxia suggest central pathology 2

Essential Physical Examination

Perform HINTS examination (Head Impulse, Nystagmus, Test of Skew) if the patient has acute persistent vertigo: 4

• Central warning signs requiring urgent imaging:
  • Nystagmus that changes direction without head position changes 5
  • Downward nystagmus in Dix-Hallpike maneuver 5
  • Vertical skew deviation 4
  • Normal head impulse test (absence of corrective saccade) 4

Do NOT perform Dix-Hallpike testing as the initial maneuver when Romberg is positive, as this suggests central rather than BPPV pathology. 4

Imaging Strategy

Immediate MRI Brain is Indicated

Order MRI brain without and with IV contrast for any patient with vertigo and positive Romberg test: 4

• MRI detects acute brain lesions in 11% of patients with acute persistent vertigo and no focal neurologic deficits 4
• 75-80% of patients with posterior circulation infarcts causing acute vestibular syndrome have no obvious focal neurologic deficits 4
• MRI with contrast improves detection of masses, inflammatory processes, demyelinating disease, and infectious etiologies 4

CT head without contrast is inadequate: Detection rate of CNS pathology is less than 1% in patients with isolated vertigo, and CT misses posterior fossa strokes in the acute phase 4

High-Risk Features Mandating Urgent Imaging

The following increase stroke risk to 25-75% in patients with acute vestibular syndrome: 4

• Age >50 years
• Vascular risk factors (hypertension, diabetes, smoking, atrial fibrillation)
• Positive Romberg test (indicating central involvement)
• Any associated neurologic symptoms

Common Diagnostic Pitfalls

Do Not Assume Peripheral Vestibular Disease

• 3% of treatment failures for presumed BPPV have underlying CNS disorders 5
• 10% of cerebellar strokes present similarly to peripheral vestibular processes 5
• A positive Romberg test fundamentally changes the differential diagnosis away from common peripheral causes 2

Do Not Delay Imaging Based on "Normal" Neurologic Exam

• One-third to two-thirds of posterior circulation strokes lack focal neurologic signs on initial examination 4
• The HINTS examination (when properly performed by trained practitioners) is more sensitive than early MRI for stroke detection (100% vs 46%), but this requires specialized training 4

Management Algorithm

1. Stabilize the patient: Address nausea/vomiting with antiemetics if needed 6

2. Obtain urgent MRI brain without and with contrast 4

3. If MRI shows posterior circulation stroke or cerebellar infarct:

   • Activate stroke protocol
   • Neurology consultation
   • Consider thrombolysis or thrombectomy if within appropriate time window 5

4. If MRI shows demyelinating disease (multiple sclerosis):

   • Neurology referral for disease-modifying therapy 4

5. If MRI shows mass lesion:

   • Neurosurgery consultation 4

6. If MRI is negative, consider:

   • Spinal cord imaging (cervical/thoracic MRI) for posterior column pathology
   • Vitamin B12 deficiency, copper deficiency, tabes dorsalis
   • Peripheral neuropathy evaluation

What NOT to Do

• Do not treat empirically as BPPV without first excluding central causes 4, 5
• Do not perform canalith repositioning maneuvers until central pathology is excluded 4
• Do not discharge without imaging when Romberg is positive with vertigo 4
• Do not rely on CT head as definitive imaging for this presentation 4