A 68-year-old with hypertension develops continuous vertigo, vomiting and inability to walk without support. Head-impulse testing is normal, direction-changing gaze-evoked nystagmus is present and there is skew deviation. What is the most appropriate action?
The HINTS pattern described is central rather than peripheral. A normal head impulse in a severe acute vestibular syndrome is not reassuring and should trigger urgent stroke-pathway assessment.
A. Perform an Epley manoeuvre: BPPV causes brief positional episodes, not a continuous central-pattern vestibular syndrome.
B. Discharge with vestibular suppressants: This risks missing a time-critical posterior-circulation event.
C. Diagnose vestibular neuritis because hearing is normal: Normal hearing does not exclude stroke.
D. Treat as a possible posterior-circulation stroke and arrange urgent stroke assessment: The HINTS pattern described is central rather than peripheral. A normal head impulse in a severe acute vestibular syndrome is not reassuring and should trigger urgent stroke-pathway assessment.
E. Arrange routine outpatient MRI: Urgency is determined by the acute central signs, not merely by the preferred imaging modality.
If head impulse were abnormal, nystagmus unidirectional and no skew were present in an otherwise typical case, peripheral vestibular neuritis would become more likely.
Draft Clinora educational material only; not official JCIE content, an accredited programme, or a substitute for local policy and specialist judgement.
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