What is the likely diagnosis for a patient with dizziness swaying to the left, numbness in the left neck and jaw, and tingling in the left toe?

Urgent Evaluation for Posterior Circulation Stroke Required

This constellation of symptoms—dizziness with lateralizing neurological deficits (left-sided numbness in neck/jaw and tingling in left toe)—represents a central nervous system process until proven otherwise, most concerning for posterior circulation stroke or transient ischemic attack. 1

Critical Red Flags Present

Your symptom pattern contains multiple red flags that distinguish this from benign peripheral vertigo:

• Lateralizing sensory deficits (numbness in left neck/jaw, tingling in left toe) indicate central pathology—these are NOT features of peripheral vestibular disorders like BPPV 1, 2
• Severe postural instability ("swaying") is characteristic of vertebrobasilar insufficiency and cerebellar lesions, producing significantly more balance impairment than peripheral causes 1, 2
• The combination of vertigo with additional neurological symptoms (sensory deficits) demands immediate neuroimaging 1, 2

Why This Is NOT Benign Peripheral Vertigo

Peripheral vestibular disorders (BPPV, vestibular neuritis, Ménière's disease) do NOT cause:

• Sensory deficits in the face, neck, or extremities 1
• Lateralizing neurological findings 1
• Persistent severe postural instability with falling 1, 2

Approximately 25% of patients presenting with acute vestibular syndrome have cerebrovascular disease, rising to 75% in high vascular risk cohorts. 1 Critically, 75-80% of stroke-related acute vestibular syndrome patients have NO focal neurologic deficits initially, making stroke easy to miss. 2

Immediate Action Required

You need urgent MRI brain with diffusion-weighted imaging (DWI) immediately. 1, 2 The diagnostic yield of routine CT head is less than 1% in isolated dizziness, but MRI with DWI is essential when central pathology is suspected. 1

Do NOT wait for additional symptoms to develop—isolated transient vertigo may precede vertebrobasilar stroke by weeks or months. 1, 3

Differential Diagnosis Priority

1. Posterior circulation stroke/TIA (vertebrobasilar territory)—most urgent 1, 2, 3
2. Vertebrobasilar insufficiency—attacks typically last <30 minutes without hearing loss, with gaze-evoked nystagmus and severe postural instability 1
3. Multiple sclerosis or demyelinating disease—can present with vertigo and sensory deficits 2
4. Brainstem or cerebellar lesion—10% of cerebellar strokes present similar to peripheral vestibular disorders 1, 2

Common Pitfall to Avoid

The most dangerous error is attributing these symptoms to benign peripheral vertigo (BPPV) without recognizing the central red flags. 1, 2 The presence of ANY additional neurological symptoms beyond isolated vertigo mandates immediate neuroimaging—do not perform Dix-Hallpike maneuvers or attempt canalith repositioning procedures when central pathology is suspected. 1

Dizziness is the most common symptom of posterior circulation TIA and can be more frequent before posterior circulation strokes. 3 This entity carries a high risk of recurrent events and requires aggressive medical management with antiplatelet therapy, statin use, and risk factor modification. 3