What is the best course of action for a patient presenting with vertigo, neck stiffness, and anxiety, considering their age and medical history?

Urgent Evaluation for Posterior Circulation Stroke

This patient requires immediate neurologic assessment and urgent MRI brain without contrast, as neck stiffness combined with vertigo is a red flag for posterior circulation stroke or other serious central pathology. 1, 2

Critical Red Flags Present

This presentation contains multiple concerning features that mandate urgent evaluation:

• Neck stiffness with vertigo suggests possible central pathology including stroke, meningitis, or posterior fossa lesions 1, 3
• Anxiety may be a symptom rather than a cause—patients with acute vestibular syndrome often experience severe anxiety as part of the neurologic presentation 1
• Up to 75-80% of posterior circulation strokes causing acute vestibular syndrome have NO focal neurologic deficits initially, making clinical examination alone unreliable 1, 2

Immediate Clinical Assessment

Perform HINTS Examination (if trained)

• Head Impulse test: Normal (corrective saccade) suggests central cause 1, 2
• Nystagmus pattern: Direction-changing or vertical nystagmus indicates central pathology 1, 2
• Test of Skew: Vertical eye misalignment suggests brainstem involvement 1, 2

Critical caveat: HINTS has 100% sensitivity for stroke only when performed by trained practitioners; when performed by non-experts, results are unreliable 1, 2

Assess for Additional Stroke Risk Factors

• Age >50 years, hypertension, diabetes, atrial fibrillation, or prior stroke increases posterior circulation stroke risk to 11-25% even with normal neurologic exam 1, 2

Imaging Strategy

MRI brain without contrast is mandatory for this presentation 1, 2:

• MRI has 4% diagnostic yield versus <1% for CT in isolated dizziness 1
• CT misses most posterior circulation infarcts and has only 20-40% sensitivity 1
• Diffusion-weighted imaging is essential for detecting acute ischemia 1, 4

Do NOT rely on CT head—it is inadequate for detecting posterior fossa pathology and will miss the majority of strokes causing vertigo 1, 2

Rule Out Meningitis

Given neck stiffness, assess for:

• Fever, severe headache, photophobia 1
• Kernig's or Brudzinski's signs
• If meningeal signs present, lumbar puncture may be needed after imaging excludes mass effect

Consider Peripheral Causes Only After Excluding Central Pathology

Once imaging excludes stroke and other central causes, consider:

Benign Paroxysmal Positional Vertigo (BPPV)

• Perform Dix-Hallpike maneuver: Brief (<60 seconds) rotatory nystagmus with 5-20 second latency 1, 2, 5
• If positive and no red flags, treat with Epley maneuver (90-98% success rate) 1, 5
• No imaging needed for typical BPPV with positive Dix-Hallpike 1, 5

Vestibular Neuritis

• Acute persistent vertigo lasting days with severe nausea/vomiting 6
• NO hearing loss, tinnitus, or aural fullness 6
• Horizontal nystagmus that lessens with visual fixation 6

Ménière's Disease

• Episodes lasting 20 minutes to 12 hours 6, 1
• Fluctuating hearing loss, tinnitus, or aural fullness 6, 1
• Obtain audiogram if suspected 1

Management of Anxiety

Do not attribute symptoms to anxiety until central causes are excluded 1:

• Anxiety is often a secondary response to acute vestibular dysfunction 1
• Persistent dizziness with chronic anxiety may warrant psychiatric evaluation and cognitive behavioral therapy only after organic causes ruled out 1

Medication Considerations

Meclizine is FDA-approved for vertigo associated with vestibular system diseases 7:

• Appropriate for peripheral vertigo (BPPV, vestibular neuritis) after diagnosis confirmed 7
• NOT appropriate for acute presentations requiring urgent evaluation 7
• Does not treat underlying pathology—canalith repositioning procedures are superior for BPPV 1, 5

Common Pitfalls to Avoid

• Assuming normal neurologic exam excludes stroke—this is the most dangerous error 1, 2
• Ordering CT instead of MRI—CT has unacceptably low sensitivity for posterior circulation pathology 1, 2
• Attributing symptoms to anxiety prematurely—always exclude organic causes first 1
• Performing Dix-Hallpike when neck stiffness present—image first to rule out central pathology 2
• Relying on patient's description of "spinning"—focus on timing, triggers, and associated symptoms instead 1