A 62-year-old man presents with acute continuous vertigo of 6 hours duration. Bedside examination shows a normal video head impulse test bilaterally, direction-changing nystagmus on lateral gaze, and a vertical misalignment of the eyes that corrects on alternate cover testing. The most appropriate next step is:
- A Urgent neuroimaging to exclude posterior circulation infarction ✓
- B Canalith repositioning manoeuvre
- C High-dose corticosteroids for vestibular neuritis
- D Betahistine therapy and reassurance
Correct answer: A. Urgent neuroimaging to exclude posterior circulation infarction
Explanation
The HINTS battery distinguishes central from peripheral acute vestibular syndrome. B normal head impulse test, direction-changing (bidirectional) nystagmus, and skew deviation form the 'central' pattern and predict posterior fossa stroke better than early MRI. Vestibular neuritis requires an abnormal head impulse test with unidirectional nystagmus, which kills option C. Repositioning manoeuvres treat BPPV, which produces brief positional rather than continuous vertigo.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.