What is the diagnosis for a patient presenting with vertigo and mild left‑hand and left‑foot numbness in the setting of severe hypertension?

Acute Posterior Circulation Stroke Until Proven Otherwise

This presentation of spinning vertigo with focal neurological deficits (left-sided numbness) in the setting of severe hypertension (200/110 mmHg) represents a posterior circulation stroke or TIA until proven otherwise and requires emergent neuroimaging and stroke protocol activation. 1

Critical Diagnostic Reasoning

Why This is Likely Stroke/TIA

• Vertigo plus focal neurological signs = vascular cause: The combination of acute vertigo with motor/sensory deficits strongly suggests vertebrobasilar ischemia rather than benign peripheral vestibular disease 2, 1

• Severe hypertension is a major red flag: Hypertension is the primary modifiable risk factor for posterior circulation stroke, and your patient's BP of 200/110 mmHg significantly elevates stroke risk 2, 3

• Unilateral sensory deficits indicate central pathology: Left hand and foot numbness suggests involvement of central sensory pathways (brainstem or thalamus) rather than peripheral vestibular structures 1, 4

High-Risk Clinical Score

Using validated risk stratification, this patient scores high on the Sudbury Vertigo Risk Score with multiple risk factors present: hypertension, motor/sensory deficits, and likely age >65 2. Patients with these features have up to a 41% risk of serious diagnosis (stroke, TIA, vertebral artery dissection) when the score exceeds 8 points 2.

Immediate Management Algorithm

Step 1: Emergent Neuroimaging

• MRI with diffusion-weighted imaging (DWI) is the gold standard: DWI-MRI has superior sensitivity for detecting acute posterior circulation infarcts compared to CT, with diagnostic yield increasing to 12% when neurological findings are present 5, 4
• If MRI unavailable or contraindicated, obtain non-contrast head CT immediately to rule out hemorrhage, though sensitivity for early ischemic stroke is limited 5

Step 2: Vascular Imaging

• CT angiography (CTA) or MR angiography (MRA) of head and neck: Essential to evaluate vertebral and basilar arteries for stenosis, dissection, or occlusion 1, 6
• Vertebral artery dissection can present with vertigo and should be considered, with CTA demonstrating nearly 100% sensitivity 5

Step 3: Blood Pressure Management

• Do NOT aggressively lower BP acutely unless >220/120 mmHg: In acute ischemic stroke without reperfusion therapy, guidelines recommend against routine BP lowering unless SBP ≥220 mmHg or DBP ≥120 mmHg 3
• If BP reduction needed, aim for modest 15% reduction within 24 hours to avoid worsening cerebral perfusion 3
• Critical pitfall: Overly aggressive BP lowering in acute stroke can extend the ischemic penumbra and worsen outcomes 7, 3

Step 4: Stroke Protocol Activation

• Activate stroke team immediately for potential thrombolysis or thrombectomy consideration 3
• Time-sensitive interventions require rapid evaluation and decision-making

Key Differential Considerations

Vertebrobasilar Insufficiency (VBI)

• Chronic VBI can present with episodic vertigo and neurological deficits 5, 1
• However, the acute presentation with severe hypertension makes acute stroke/TIA more likely than chronic insufficiency 6

Isolated Labyrinthine Infarction

• Can present with acute vertigo without obvious brainstem signs 1, 4
• However, the presence of sensory deficits makes this diagnosis less likely, as labyrinthine infarction typically causes isolated vestibular symptoms 1

Vertebral Artery Dissection

• Should be considered in any patient with acute vertigo and vascular risk factors 1
• Requires specific vascular imaging for diagnosis 5

Critical Pitfalls to Avoid

• Never dismiss vertigo with neurological signs as "benign positional vertigo": BPPV does not cause sensory deficits 5, 1
• Do not delay imaging for bedside testing: While HINTS exam (Head Impulse, Nystagmus, Test of Skew) can help differentiate peripheral from central causes, the presence of focal neurological deficits already indicates central pathology requiring immediate imaging 5, 1
• Avoid excessive BP lowering: This is a hypertensive urgency in the context of possible stroke, not a hypertensive emergency requiring aggressive IV therapy 7, 3

Admission and Follow-up

• Admit to stroke unit or intensive care: Patients with posterior circulation stroke/TIA require monitored setting 7
• Initiate secondary stroke prevention: antiplatelet therapy, statin, and long-term BP control targeting <130/80 mmHg after acute phase 3
• Address modifiable risk factors including hypertension management 6, 3