Normal head impulse test differentiates acute cerebellar strokes from vestibular neuritis

Document Type

Article

Abstract

OBJECTIVE: To test the diagnostic accuracy of the horizontal head impulse test (h-HIT) of vestibulo-ocular reflex (VOR) function in distinguishing acute peripheral vestibulopathy (APV) from stroke. Most patients with acute vertigo, nausea/vomiting, and unsteady gait have benign APV (vestibular neuritis or labyrinthitis) as a cause. However, some harbor life-threatening brainstem or cerebellar strokes that mimic APV. A positive h-HIT (abnormal VOR) is said to predict APV. METHODS: Cross-sectional study at an urban, academic hospital over 6 years. Consecutive acute vestibular syndrome patients at high risk for stroke underwent structured examination (including h-HIT), neuroimaging, and admission. Stroke was confirmed by neuroimaging (MRI or CT). APV was diagnosed by normal MRI and appropriate clinical evolution in follow-up. RESULTS: Forty-three subjects enrolled. One had an equivocal h-HIT. Patients with APV had a positive h-HIT (n = 8/8, 100%). Most patients with stroke had a negative h-HIT (n = 31/34, 91%). However, contrary to conventional wisdom, three patients with stroke (9%) demonstrated a positive h-HIT (1 vestibulocerebellar, 1 pontocerebellar, 1 pontocerebello-labyrinthine stroke). CONCLUSIONS: Patients with lateral pontine and cerebellar strokes can have a positive horizontal head impulse test (h-HIT), so the sign's presence cannot be solely relied upon to identify a benign pathology. Additional clinical features (e.g., directionality of nystagmus, severity of truncal instability, nature of hearing loss) must be considered in patients with acute vestibular syndrome with a positive h-HIT before a central localization can be confidently excluded. Nonetheless, the h-HIT remains a useful bedside test-in acute vestibular syndrome patients, a negative h-HIT (i.e., normal VOR) strongly suggests a central lesion with a pseudo-labyrinthine presentation.

Medical Subject Headings

Adult; Aged; Aged, 80 and over; Cerebellar Diseases (complications, diagnosis); Cerebellum (blood supply); Cross-Sectional Studies; Diagnosis, Differential; Female; Humans; Male; Middle Aged; Physical Examination; Predictive Value of Tests; Prospective Studies; Reflex, Vestibulo-Ocular; Stroke (complications, diagnosis); Vestibular Neuronitis (complications, diagnosis)

Publication Date

6-10-2008

Publication Title

Neurology

E-ISSN

1526-632X

Volume

70

Issue

24 Pt 2

First Page

2378

Last Page

85

PubMed ID

18541870

Digital Object Identifier (DOI)

10.1212/01.wnl.0000314685.01433.0d

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