What is the initial workup and treatment for an inpatient with central vertigo?

Central Vertigo Inpatient Workup

For inpatients with central vertigo, obtain urgent MRI brain without and with IV contrast as first-line imaging, perform a comprehensive neurological examination with HINTS testing, and initiate stroke protocol if imaging confirms posterior circulation infarct. 1, 2

Immediate Clinical Assessment

Neurological Examination

• Perform a thorough neurological examination focusing on cranial nerve deficits, severe postural instability (inability to stand or walk), and focal neurologic signs—these are red flags for central pathology requiring urgent intervention 2, 3
• Conduct the HINTS examination (Head Impulse, Nystagmus, Test of Skew) which has 92.9% sensitivity and 83.4% specificity for central causes when performed by trained clinicians 2
• Central warning signs on HINTS include: normal head impulse test (absence of corrective saccade), nystagmus that changes direction without head position changes, downward nystagmus, and vertical skew deviation 4, 3
• Document associated symptoms including severe headache, auditory symptoms (sudden hearing loss, unilateral tinnitus), and autonomic dysfunction 1, 2

Risk Stratification

• Identify high-risk features: age >50 with vascular risk factors (hypertension, coronary artery disease, diabetes), history of stroke or TIA, and unresponsiveness to initial treatment 2, 5
• Note that 75-80% of patients with posterior circulation infarcts causing acute vestibular syndrome have no obvious focal neurologic deficits initially—normal neurologic exam does NOT exclude stroke 2, 3

Imaging Strategy

First-Line Imaging

• Order urgent MRI brain without and with IV contrast for all inpatients with suspected central vertigo—this is the gold standard and detects acute brain lesions in 11% of patients with acute persistent vertigo and no focal neurologic deficits 1, 2, 4
• MRI with diffusion-weighted imaging has significantly higher diagnostic yield (4-16%) compared to CT and is essential for detecting posterior circulation infarcts, which are the most common central cause 3
• CT head without contrast is inadequate—it has very low diagnostic yield (<1%) for isolated vertigo, sensitivity of only 20-40% for causative pathology, and misses posterior fossa strokes in the acute phase 2, 4, 3

Additional Imaging When Indicated

• Consider MRA head and neck if MRI brain is negative but vertebrobasilar insufficiency is suspected based on episodic symptoms and vascular risk factors 1, 2
• Order CT temporal bone without IV contrast only if there are auditory symptoms suggesting structural inner ear pathology after central causes are excluded 2
• If MRI brain is negative and Romberg test remains positive, consider spinal cord imaging (cervical/thoracic MRI) for posterior column pathology 4

Laboratory Testing

• Do not order routine blood tests (CBC, chemistry panel) as standard practice for vertigo diagnosis—the diagnosis is fundamentally clinical based on symptom timing, triggers, and physical examination 2
• Reserve laboratory testing for specific clinical scenarios: autoimmune panels for progressive fluctuating bilateral hearing loss with concurrent vision/skin/joint problems; serologic testing for Lyme disease or syphilis if severe otalgia, fever, or sudden bilateral hearing loss present 2
• Consider vitamin B12 and copper levels only if MRI suggests posterior column pathology or peripheral neuropathy 4

Management Based on Imaging Results

If MRI Shows Posterior Circulation Stroke or Cerebellar Infarct

• Activate stroke protocol immediately and consult neurology for thrombolytic therapy consideration if within appropriate time window 4
• Admit to stroke unit or ICU for monitoring of neurological status and management of cerebrovascular complications 4

If MRI Shows Demyelinating Disease

• Consult neurology for disease-modifying therapy and further workup for multiple sclerosis 4

If MRI Shows Mass Lesion

• Obtain immediate neurosurgery consultation for evaluation and management 4

If MRI is Negative

• Reassess clinical presentation and consider alternative diagnoses: vestibular migraine (treat with migraine prophylaxis), vertebrobasilar insufficiency (consider MRA), or medication-induced vertigo (review and discontinue offending agents) 2, 3
• If symptoms persist despite negative imaging, consider vestibular rehabilitation therapy as primary intervention 3

Critical Pitfalls to Avoid

• Never treat empirically as BPPV without first excluding central causes—CNS disorders masquerade as BPPV in 3% of treatment failures 1, 4
• Never perform Dix-Hallpike maneuver when Romberg test is positive—a positive Romberg indicates central pathology requiring imaging first 4
• Never discharge without imaging when central warning signs are present—this includes severe postural instability, cranial nerve deficits, or abnormal HINTS examination 2, 4
• Never rely solely on CT head as definitive imaging—CT misses many posterior circulation infarcts and has inadequate sensitivity for central vertigo workup 2, 4, 3
• Never assume normal neurologic exam excludes stroke—up to 75-80% of posterior circulation strokes causing vertigo lack focal neurologic deficits initially 2, 3

Symptomatic Treatment Considerations

• For refractory central vertigo symptoms after acute management, consider low-dose olanzapine 2.5mg daily, which has shown rapid and dramatic symptom resolution in case reports of central vertigo from brain injury and stroke 6
• Vestibular suppressants (meclizine, dimenhydrinate) are generally ineffective for central vertigo and may delay diagnosis—avoid routine use 7