Clinical Reasoning: A 55-year-old woman with vertigo

Abstract

A 55-year-old woman presented to the emergency department complaining of dizziness. Several hours earlier she abruptly felt “the room spinning and moving back and forth.” Simultaneously, she experienced nausea, vomiting, and gait unsteadiness. The dizziness exacerbated with head movement. She denied head or neck pain, photophobia, phonophobia, auditory symptoms, weakness, numbness, diplopia, dysarthria, dysphonia, dysphagia, history of recent illness, prior dizziness, or headache. Medical history included hyperlipidemia and hypertension. ### Question for consideration: 1. What is the differential diagnosis for acute vertigo? GO TO SECTION 2 To determine the cause of acute vertigo, it is important to know whether it is transient (seconds to minutes) or prolonged (hours to days); a single episode of vertigo or a recurrence; if it is positionally provoked (e.g., benign paroxysmal positional vertigo); and if there are any accompanying symptoms or signs. The most common causes of acute prolonged vertigo include a peripheral vestibulopathy, Meniere syndrome, migrainous vertigo, or brainstem or cerebellar ischemia.1 This discussion is limited to the distinction between a peripheral vestibulopathy and ischemia. The acute vestibular syndrome (AVS) develops over seconds to hours and is characterized by vertigo, nausea, vomiting, gait instability, head motion intolerance, and nystagmus.2,–,4 It is caused by either an acute peripheral vestibulopathy (APV) or brainstem/cerebellar ischemia, and similarities in presentation often make the distinction a diagnostic challenge. Transient ischemic attacks can cause acute vertigo with rapid resolution but vertigo resulting …