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Central vs Peripheral Vertigo — RACP Adult Medicine MCQ

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ModerateNeurologyCentral vs Peripheral VertigoRACP Adult Medicine

A 58-year-old man presents with acute onset vertigo, nausea, vomiting, and unsteadiness. He has a right-beating nystagmus that does not suppress with visual fixation, right-sided limb ataxia, and dysarthria. His head impulse test is NORMAL. What is the critical diagnosis to exclude?

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Correct answer: E — Ménière's disease

The HINTS exam (Head Impulse, Nystagmus, Test of Skew) is critical in acute vestibular syndrome. A NORMAL head impulse test in acute vertigo is a red flag for central cause (stroke) – peripheral vestibular lesions cause an abnormal (positive) HIT. Direction-changing nystagmus or nystagmus not suppressed by fixation, and skew deviation also suggest central pathology. This patient's limb ataxia and dysarthria further support a posterior circulation stroke. Urgent MRI brain (DWI) is required. CT may miss posterior fossa strokes.

Reference: Stroke Foundation – 2024 – Clinical Guidelines; eTG – 2025 – Neurology