This article provides a practical approach to acute vestibular syndrome while highlighting recent research advances.
Acute vestibular syndrome is defined as sudden-onset, continuous vertigo lasting longer than 24 hours with associated nausea and vomiting, all of which are worsened with head movement. Acute vestibular syndrome is provoked by a variety of central and peripheral causes, the most common of which are vestibular neuritis and acute stroke (posterior circulation). A clinical approach focusing on timing, associated history, and ocular motor findings can improve diagnostic accuracy and is more sensitive and specific than early neuroimaging. Because of the shared neurovascular supply, both peripheral and central vestibular disorders can manifest overlapping signs previously considered solely peripheral or central, including vertical skew, nystagmus, abnormal vestibular ocular reflex, hearing loss, and gait instability. Although acute vestibular syndrome is typically benign, stroke should be considered in every person with acute vestibular syndrome because it can act as a harbinger of stroke or impending cerebellar herniation. Treatment is focused on physical therapy because the evidence is minimal for the long-term use of medication.
The diagnosis of acute vestibular syndrome first requires the elimination of common medical causes for dizziness. Next, underlying pathology must be determined by distinguishing between the most common causes of acute vestibular syndrome: central and peripheral vestibular disorders. Central vestibular disorders are most often the result of ischemic stroke affecting the cerebellar arteries. Peripheral vestibular disorders are assumed to be caused mostly by inflammatory sources, but ischemia of the peripheral vestibular apparatus may be underappreciated. By using the HINTS Plus (Head Impulse test, Nystagmus, Test of Skew with Plus referring to hearing loss assessment) examination in addition to a comprehensive neurologic examination, strokes are unlikely to be missed. For nearly all acute vestibular disorders, vestibular physical therapy contributes to recovery.
