Hearing Loss is the Most Common Associated Feature
In a 34-year-old woman presenting with recurrent sudden "push" sensations, falls, and vertigo with a normal brain MRI, hearing loss is the most commonly associated clinical feature, pointing toward either Menière's disease or vertebrobasilar insufficiency (VBI) as the underlying diagnosis. 1
Diagnostic Reasoning
Primary Differential: Menière's Disease vs. Vertebrobasilar Insufficiency
Menière's disease is the leading consideration given the recurrent episodic pattern (six episodes over two months) and should be accompanied by:
- Fluctuating low-to-mid frequency sensorineural hearing loss in the affected ear 2
- Tinnitus and aural fullness that vary with attacks 2
- Episodes lasting 20 minutes to 12 hours by definition 2
Vertebrobasilar insufficiency remains a critical alternative diagnosis in this age group, characterized by:
- Dizziness and vertigo as the most common presenting symptoms 1, 3
- Diplopia occurring in approximately 36% of cases with accompanying neurological symptoms 4
- Hearing loss can occur with anterior inferior cerebellar artery (AICA) territory involvement 5, 6
- Episodes typically lasting seconds to minutes 7
- Headache reported in 11% of cases preceding posterior circulation stroke 4
Why the Other Options Are Less Common
Diplopia occurs in VBI but is typically accompanied by other brainstem symptoms rather than presenting as an isolated associated feature 1, 3. When diplopia is present, it suggests more extensive vertebrobasilar territory involvement 1.
Headache is reported in only 11% of transient vestibular symptoms preceding posterior circulation stroke 4, making it a less frequent association than hearing loss.
Upper respiratory infection would suggest vestibular neuritis, but this presents as a single prolonged episode lasting days to weeks, not recurrent brief episodes 2. The pattern described (recurrent episodes over two months) is inconsistent with post-viral vestibular neuritis.
Horner's syndrome would indicate lateral medullary involvement (Wallenberg syndrome) and is not a common feature of either Menière's disease or typical VBI presentations 1.
Critical Diagnostic Approach
Immediate Evaluation Required
Obtain comprehensive audiometry to document:
- Low-to-mid frequency sensorineural hearing loss pattern (Menière's) 2
- Asymmetric hearing loss requiring urgent neuroimaging 1
Assess vascular risk factors given the patient's age:
- Hypertension, diabetes, smoking, atrial fibrillation 1
- Even at age 34, vertebrobasilar insufficiency can occur with dissection or atherosclerotic disease 1
Advanced Imaging Considerations
MRI head and internal auditory canal WITH and WITHOUT contrast is indicated for:
- Chronic recurrent vertigo with unilateral hearing loss or tinnitus 1
- Excluding vestibular schwannoma 1
- Definitive diagnosis of Menière's disease with specialized protocols 1
MRA or CTA of head and neck should be obtained if:
- Vascular risk factors are present 1
- Episodes suggest vertebrobasilar insufficiency pattern 1
- Sensitivity of 94% and specificity of 95% for detecting vertebral artery stenosis 1
Common Diagnostic Pitfalls
Do not assume normal brain MRI excludes vascular pathology—standard MRI may miss:
- Vertebral artery stenosis or dissection requiring dedicated vascular imaging 1
- Small posterior circulation infarcts, especially if MRI performed >48 hours after symptoms 1
Do not rely on symptom duration alone—while Menière's episodes classically last 20 minutes to 12 hours 2, VBI can present with highly variable duration ranging from seconds to minutes 4, 7, and 12% of posterior circulation strokes are preceded by transient vestibular symptoms 4.
Do not overlook AICA territory ischemia—this can cause both vertigo and hearing loss simultaneously, mimicking Menière's disease 5, 6. Bedside hearing testing should be performed in addition to vestibular examination 8.