Four hours of vertigo — triage before treatment

The acute vestibular syndrome is the one balance presentation where the examination outranks the treatment, and the evidence is explicit about both halves of that sentence: Kattah’s three-step HINTS examination outperformed early MRI diffusion imaging in skilled hands, Newman-Toker’s HINTS-plus added the hearing check that catches the AICA territory, and the Cochrane review added the honest caveat — the sensitivity belongs to trained examiners, so the findings are written down in full and a doubtful examination escalates rather than reassures. A normal impulse, a direction-changing beat and a skew is not a difficult call: it is a central pattern, and a central pattern is a stroke until proven otherwise. What you do with it: perform and document HINTS+ before any treatment, send the central pattern back to neurology for MRI the same day, and let the rehabilitation referral wait for the scan it should have preceded.

• Normal head impulse, direction-changing nystagmus or skew deviation — central until proven otherwise; escalate the same day
• New hearing loss with the vertigo — the AICA territory supplies both, and escalation gets faster, not slower
• Cannot stand unsupported — severe truncal ataxia is itself a central warning in this syndrome

• The spinning bed — posterior canal BPPV, right earTier 1
• Vertigo with a headache — vestibular migraineTier 2

This page carries the case’s first decision. The full sequence — every decision, the examination by domain, and the debrief that grades you — is in the drill, and the library is included with membership.