skip to main content

Acute vestibular syndrome with suspected posterior circulation stroke — MRCEM SBA MCQ

Instant feedback + full explanation. One question, done properly.

HardNeurological emergenciesAcute vestibular syndrome with suspected posterior circulation strokeMRCEM SBA

A 61-year-old woman with type 2 diabetes presents two hours after the sudden onset of continuous vertigo, vomiting and inability to walk unaided. She also reports new hearing loss in her left ear. Her initial capillary glucose is 2.8 mmol/L; after intravenous glucose it is 6.2 mmol/L, but her vestibular symptoms and hearing loss are unchanged. She has no limb weakness or dysarthria. An emergency physician experienced in HINTS examination finds a normal horizontal head-impulse test, unidirectional horizontal nystagmus and no skew deviation. Turning her head worsens the vertigo, but does not trigger discrete episodes. What is the most appropriate immediate management plan?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: E — Arrange immediate stroke-pathway assessment and urgent neuroimaging.

This is an acute vestibular syndrome, not brief vertigo triggered by a change in position. Correcting the hypoglycaemia has not resolved the symptoms, and the new hearing loss is an additional warning feature. Crucially, a **normal head-impulse test** is a stroke-indicating HINTS finding in a patient with acute vestibular syndrome, even though the nystagmus is unidirectional and skew is absent. NICE recommends immediate neuroimaging when HINTS indicates stroke, and immediate referral to exclude posterior circulation stroke when sudden dizziness with a focal feature persists after hypoglycaemia is treated. Suspected stroke warrants specialist stroke assessment and appropriate imaging; the patient should not be routed first to a non-stroke service. ([nice.org.uk](https://www.nice.org.uk/guidance/ng127/chapter/recommendations-for-adults-aged-over-16)) **A** is attractive because vertigo with hearing loss can suggest labyrinthitis, but it does not account safely for the stroke-indicating HINTS result. **B** addresses the hearing loss but delays assessment of a possible posterior circulation stroke. **C** would fit symptoms that resolved after glucose correction; these have persisted. **D** would fit brief, position-triggered attacks rather than continuous vertigo with gait unsteadiness and a central HINTS sign. ([nice.org.uk](https://www.nice.org.uk/guidance/ng127/chapter/recommendations-for-adults-aged-over-16))

Reference: NICE NG127, recommendations 1.2.1–1.2.3 (2 October 2023) — https://www.nice.org.uk/guidance/ng127/chapter/recommendations-for-adults-aged-over-16 NICE NG128, specialist stroke units and brain imaging (13 April 2022) — https://www.nice.org.uk/guidance/ng128/chapter/Recommendations