A patient presents with acute severe vertigo, vomiting, inability to walk, and nystagmus that does NOT suppress with visual fixation. Direction of nystagmus changes on gaze direction (gaze-evoked nystagmus). The HEAD IMPULSE TEST is normal (no corrective saccade). This presentation most strongly suggests:
- A Vestibular neuritis — peripheral cause
- B Benign paroxysmal positional vertigo — canalith repositioning indicated
- C Posterior fossa stroke (central vestibular cause) — urgent MRI required ✓
- D Labyrinthitis — treat with vestibular suppressants
Explanation
The HINTS examination (Head Impulse test, Nystagmus type, Test of Skew) distinguishes central from peripheral acute vestibular syndrome. A NORMAL head impulse test (no corrective saccade — meaning VOR is intact, the labyrinth is likely fine), DIRECTION-CHANGING nystagmus, and presence of skew deviation all point to a CENTRAL lesion (posterior fossa stroke/cerebellar haemorrhage/infarct), not peripheral vestibular neuritis. In vestibular neuritis, the head impulse test is ABNORMAL (positive catch-up saccade). Normal HIT + direction-changing nystagmus = central — urgent brain MRI with DWI is mandatory to exclude posterior fossa stroke, which can be missed on CT.
Reference: Dhingra Diseases of Ear, Nose and Throat, 7th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.