What are the physical exam findings associated with central nervous system (CNS) causes of acute vertigo?

From the Guidelines

Physical exam findings associated with central nervous system causes for acute vertigo include nystagmus that changes direction with gaze, vertical nystagmus, pure torsional nystagmus, or nystagmus that cannot be suppressed with visual fixation, as well as other neurological deficits such as dysarthria, dysphagia, limb ataxia, and abnormal gait. These findings can be identified through a thorough physical examination, including:

• Nystagmus findings, such as downbeating nystagmus on the Dix-Hallpike maneuver, direction-changing nystagmus, gaze holding, and direction-switching nystagmus 1
• Dysarthria, dysphagia, and limb ataxia, which can indicate brainstem or cerebellar involvement 1
• Abnormal gait, including inability to walk without support, which can suggest cerebellar or brainstem dysfunction 1
• Skew deviation, abnormal head impulse test, and normal vestibulo-ocular reflex, which can indicate central nervous system pathology 1
• Facial numbness, facial weakness, hearing loss, diplopia, Horner's syndrome, and altered consciousness, which can be associated with brainstem or cerebellar lesions 1
• Other neurological deficits, such as hemiparesis, hemianopia, or other cranial nerve abnormalities, which can suggest central nervous system involvement 1

These physical exam findings can help differentiate central nervous system causes of acute vertigo from peripheral vestibular causes, and guide further evaluation and management. The presence of multiple neurological signs beyond isolated vertigo is particularly concerning for a central cause such as stroke, multiple sclerosis, or other intracranial pathology 1.

From the Research

Physical Exam Findings for Central Nervous System Cause of Acute Vertigo

The following physical exam findings can be associated with a central nervous system cause of acute vertigo:

• General neurologic examination: sensitivity 46.8% (95% CI 32.3%-61.9%, moderate certainty) and specificity 92.8% (95% CI 75.7%-98.1%, low certainty) 2
• Limb weakness/hemiparesis: sensitivity 11.4% (95% CI 5.1%-23.6%, high) and specificity 98.5% (95% CI 97.1%-99.2%, high) 2
• Truncal/gait ataxia: sensitivity 69.7% (43.3%-87.9%, low) and specificity 83.7% (95% CI 52.1%-96.0%, low) 2
• Dysmetria signs: sensitivity 24.6% (95% CI 15.6%-36.5%, high) and specificity 97.8% (94.4%-99.2%, high) 2
• Head impulse test (HIT): sensitivity 76.8% (64.4%-85.8%, low) and specificity 89.1% (95% CI 75.8%-95.6%, moderate) 2
• Spontaneous nystagmus: sensitivity 52.3% (29.8%-74.0%, moderate) and specificity 42.0% (95% CI 15.5%-74.1%, moderate) 2
• Nystagmus type (bidirectional, vertical, direction changing, or pure torsional nystagmus): sensitivity 50.7% (95% CI 41.1%-60.2%, moderate) and specificity 98.5% (95% CI 91.7%-99.7%, moderate) 2
• Test of skew: sensitivity 23.7% (95% CI 15%-35.4%, moderate) and specificity 97.6% (95% CI 96%-98.6%, moderate) 2
• HINTS (head impulse, nystagmus, test of skew): sensitivity 92.9% (95% CI 79.1%-97.9%, high) and specificity 83.4% (95% CI 69.6%-91.7%, moderate) 2
• HINTS+ (HINTS with hearing component): sensitivity 99.0% (95% CI 73.6%-100%, high) and specificity 84.8% (95% CI 70.1%-93.0%, high) 2
• Central fixation nystagmus (e.g., downbeat nystagmus) 3
• Gaze-evoked nystagmus 3
• Central positional nystagmus 3
• Head-shaking nystagmus with cross-coupling (i.e., horizontal head shaking causing inappropriate vertical nystagmus) 3

Additional Findings

Other physical exam findings that may be associated with central nervous system cause of acute vertigo include:

• Smooth pursuit deficits 3
• Gaze-holding deficits 3
• Saccade accuracy deficits 3
• Fixation-suppression of the vestibulo-ocular reflex deficits 3
• Posturography and gait analysis abnormalities 3