What is the recommended approach to assess and initially manage an adult patient presenting with central vertigo, including history for red‑flag features, physical examination (HINTS), emergent neuroimaging, laboratory work‑up, and acute treatment options?

Assessment and Initial Management of Central Vertigo

For patients with suspected central vertigo, immediately perform the HINTS examination (Head Impulse, Nystagmus, Test of Skew) and obtain urgent MRI brain without and with IV contrast if any red-flag features are present, as HINTS has 92.9% sensitivity for detecting central causes and MRI is essential since CT misses most posterior circulation strokes. 1

Red-Flag Features Requiring Urgent Evaluation

History Red Flags

• Age >50 years with vascular risk factors (hypertension, diabetes, atrial fibrillation, prior stroke) increases posterior circulation stroke risk to 11-25% even with normal neurologic examination 1
• Severe postural instability or inability to stand/walk suggests cerebellar involvement requiring immediate imaging 1, 2
• New severe headache accompanying vertigo mandates immediate MRI and neurologic consultation 2
• Sudden unilateral hearing loss is a red flag requiring urgent neuroimaging 1
• Focal neurologic symptoms including diplopia, dysphagia, dysarthria, or limb weakness indicate brainstem or cerebellar pathology 3
• Vertigo lasting days without improvement in high-risk patients warrants imaging even without focal deficits 1

Critical Pitfall to Avoid

• Up to 75-80% of posterior circulation strokes causing acute vestibular syndrome present without focal neurologic deficits initially, so a normal neurologic examination does NOT exclude stroke 1, 2, 3

Physical Examination: HINTS Protocol

HINTS Components (Perform in Order)

• Head Impulse Test: Normal (corrective saccade absent) suggests central cause; abnormal (corrective saccade present) suggests peripheral 1, 2
• Nystagmus Pattern: Direction-changing, purely vertical (upbeating or downbeating), or gaze-evoked nystagmus indicates central pathology 1, 3, 4
• Test of Skew: Vertical skew deviation present suggests central cause 1, 2

HINTS Interpretation

• Any ONE central feature (normal head impulse, direction-changing/vertical nystagmus, or skew deviation) indicates high stroke risk requiring urgent MRI 1, 5
• HINTS has 100% sensitivity when performed by trained practitioners versus only 46% sensitivity for early MRI 2
• HINTS performed by non-experts is less reliable; if uncertain, obtain imaging for high-risk patients 2

Additional Examination Findings

• Severe truncal ataxia out of proportion to vertigo suggests cerebellar stroke 3, 4
• Cranial nerve deficits (facial weakness, dysarthria, dysphagia) indicate brainstem involvement 3, 6
• Romberg test positive indicates central pathology requiring imaging before performing Dix-Hallpike 1

Emergent Neuroimaging Strategy

When to Image Urgently

• MRI brain without and with IV contrast is first-line for: 1
  • Positive Romberg test
  • Central warning signs on HINTS examination
  • Severe postural instability or inability to walk
  • Any focal neurologic deficits
  • Age >50 with vascular risk factors, even with normal exam
  • New severe headache
  • Sudden unilateral hearing loss

Imaging Modality Selection

• MRI with diffusion-weighted imaging has 4% diagnostic yield versus <1% for CT and is essential for detecting posterior circulation strokes 1, 2
• CT head without contrast is inadequate for isolated vertigo and misses most posterior fossa strokes in the acute phase 1, 2
• MRA head and neck can detect vertebrobasilar insufficiency in episodic vertigo that cannot be confidently categorized as peripheral 1

Critical Imaging Pitfall

• Never rely on CT alone when stroke is suspected—it has only 20-40% sensitivity for causative pathology in vertigo and misses most posterior circulation infarcts 2

Laboratory Work-Up

General Approach

• Routine blood tests (CBC, chemistry) are NOT recommended as standard practice for vertigo evaluation, as diagnosis is fundamentally clinical 1
• Check fingerstick glucose immediately—hypoglycemia is the most frequently identified unexpected abnormality 1

Specific Clinical Scenarios Requiring Labs

• Suspected autoimmune causes: Order autoimmune panels for progressive fluctuating bilateral hearing loss with concurrent vision, skin, or joint problems 1
• Suspected infectious causes: Order appropriate serologic testing for Lyme disease or otosyphilis presenting with vertigo, severe otalgia, fever, or sudden bilateral hearing loss 1
• Basic metabolic panel: Consider only if history or examination suggests specific abnormalities (dehydration, electrolyte disturbance) 1

Acute Treatment Options

When Central Cause is Confirmed or Suspected

• Immediate neurologic consultation for stroke protocol activation if within treatment window 2
• Admit for monitoring if cerebellar stroke with risk of edema and herniation 7
• Antiplatelet or anticoagulation per stroke guidelines if ischemic stroke confirmed 7

Symptomatic Management

• Avoid vestibular suppressants (meclizine, benzodiazepines) in suspected central vertigo as they can mask neurologic deterioration and delay diagnosis 1
• Symptomatic treatment should be minimal until central cause is excluded or confirmed 8

Treatment Failure Recognition

• CNS disorders masquerade as BPPV in 3% of treatment failures—any patient not responding to appropriate peripheral vertigo treatment requires reevaluation with thorough neurologic examination and MRI 9
• Atypical or refractory symptoms after 2-3 attempted canalith repositioning maneuvers warrant MRI of brain and posterior fossa 9

Common Diagnostic Pitfalls

• Misdiagnosing central causes as BPPV occurs in 3% of cases—always reassess treatment failures 9
• Assuming "spinning" description confirms peripheral cause—focus on timing, triggers, and examination findings instead 1, 2
• Performing Dix-Hallpike when Romberg is positive—this indicates central pathology requiring imaging first 1
• Relying on patient's subjective description rather than objective timing (seconds vs minutes vs days) and triggers 1, 6