A 40-year-old patient with sudden onset severe vertigo, horizontal nystagmus beating to the right, and inability to walk is evaluated. Video head impulse test (vHIT) shows normal VOR gain bilaterally. Which of the following diagnoses is most consistent with these findings?

• A Acute cerebellar stroke (posterior inferior cerebellar artery territory) ✓
• B Right vestibular neuritis
• C Left vestibular neuritis
• D Benign paroxysmal positional vertigo (BPPV)

Explanation

Vestibular neuritis (peripheral) causes impaired VOR gain on the affected side, demonstrated by corrective saccades (catch-up saccades) on vHIT when the head is turned toward the damaged labyrinth. Normal vHIT gain despite severe ongoing vertigo and nystagmus strongly suggests a central cause — classically, posterior fossa stroke (particularly AICA or PICA territory cerebellar infarction). This is the HINTS exam concept: normal HIT + direction-changing nystagmus or skew deviation indicates a central cause. Normal vHIT with severe vertigo mandates urgent neuroimaging.

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.