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neuro.acute-vestibular-syndrome.v1PRODUCTION
neuro.acute-vestibular-syndrome.v1

Acute Vestibular Syndrome (HINTS pivot for central vs peripheral)

neurologyacutesubacuteadult
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Differentiate posterior-circulation stroke from vestibular neuritis in continuous-vertigo-with-nystagmus patient; CT misses ~80% of acute posterior strokes — HINTS is the diagnostic battery (Kattah Stroke 2009 PMID 19762709)

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AVS syndrome recognised; not positional / episodic

Patient inputs (15)

Age >60 + vascular risk factors elevate posterior-circulation stroke probability (Newman-Toker Acad Emerg Med 2013 PMID 24127701)

Hypertensive substrate for posterior-circulation stroke; BP cushion before any vestibular suppressant (GRACE-3 PMID 37166022)

HTN, DM, smoking, AF, prior stroke / TIA, anticoag — pre-test probability for posterior-circulation stroke (Newman-Toker Acad Emerg Med 2013 PMID 24127701)

Continuous-with-nystagmus = AVS (HINTS pathway); positional-brief = BPPV (Dix-Hallpike pathway); episodic = vestibular migraine / Meniere / TIA (Tarnutzer CMAJ 2011 PMID 21576300; GRACE-3 PMID 37166022)

AVS definition requires ≥24 h continuous vertigo + nystagmus + n/v + gait unsteadiness (Hotson/Baloh NEJM 1998 PMID 9725927)

HIT corrective saccade = peripheral; smooth tracking = central (paradoxically — preserved VOR points to central) (Kattah Stroke 2009 PMID 19762709)

Unidirectional + horizontal-torsional = peripheral; direction-changing or pure vertical/torsional = central (Kattah Stroke 2009 PMID 19762709)

Vertical misalignment on alternate cover test = central (brainstem); absent skew = peripheral (Kattah Stroke 2009 PMID 19762709)

Sudden SNHL + vertigo = AICA stroke until proven otherwise — HINTS-plus marker (Newman-Toker Acad Emerg Med 2013 PMID 24127701; GRACE-3 PMID 37166022)

Severity of gait unsteadiness — patients who cannot stand unaided have higher central risk (GRACE-3 PMID 37166022)

Vertebral artery dissection risk; pursue CTA/MRA if neck pain + vertigo (GRACE-3 PMID 37166022)

Anticonvulsants (phenytoin/carbamazepine), aminoglycosides, salicylates, SSRIs can cause vertigo / cerebellar signs (Hotson/Baloh NEJM 1998 PMID 9725927)

Wernicke encephalopathy (chronic alcohol or hyperemesis gravidarum) can present with vertigo + nystagmus + ataxia — empiric thiamine if any suspicion before glucose (GRACE-3 PMID 37166022)

Dix-Hallpike to rule out posterior canal BPPV before invoking HINTS pathway (GRACE-3 PMID 37166022)

eGFR drives contrast-MRI / CTA decisions and gentamicin-intratympanic eligibility (CKD-EPI 2021 per panel.renal)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationallife_threateningcentral_hints_pattern
    Any central HINTS feature: normal head impulse OR direction-changing nystagmus OR skew deviation positive (Kattah Stroke 2009 PMID 19762709)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninghints_plus_sudden_snhl
    Sudden sensorineural hearing loss + AVS — AICA-territory stroke pivot (Newman-Toker Acad Emerg Med 2013 PMID 24127701)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_headache_or_neck_pain_with_avs
    Severe occipital headache or neck pain + AVS — vertebral artery dissection trigger (GRACE-3 PMID 37166022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereuninterpretable_hints_or_inability_to_perform
    HINTS exam uninterpretable (untrained clinician, intolerant patient, ongoing vomiting) (Edlow GRACE-3 PMID 37166022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereposterior_circulation_tia_features
    Drop attacks, transient diplopia, dysarthria, dysphagia, hemianopia, or limb ataxia preceding / accompanying vertigo (Hotson/Baloh NEJM 1998 PMID 9725927)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresuspected_wernicke_encephalopathy
    Chronic alcohol use OR hyperemesis gravidarum OR bariatric surgery OR refeeding + AVS-like presentation (Hotson/Baloh NEJM 1998 PMID 9725927)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateelderly_with_vascular_risk
    Age >60 + ≥1 vascular risk (HTN, DM, smoking, AF, prior stroke, anticoag) + AVS (Newman-Toker Acad Emerg Med 2013 PMID 24127701)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepersistent_postural_perceptual_dizziness_PPPD
    Persistent dizziness >3 mo after AVS / vestibular neuritis with normal exam — PPPD (functional vestibular)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatebppv_positive_dix_hallpike
    Dix-Hallpike positive — posterior canal BPPV (positional brief vertigo) — NOT AVS (GRACE-3 PMID 37166022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatemeniere_features_recurrent_episodic
    Recurrent episodic vertigo + low-tone SNHL + tinnitus + aural fullness — Meniere disease — yield to dedicated engine
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

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Recommended regimen

AVS treatment ladder: vestibular neuritis steroids + symptom control + vestibular rehab + Wernicke rescue + BPPV / Meniere arms (Strupp NEJM 2004 PMID 15269315; GRACE-3 PMID 37166022)
axis: avs_treatment_ladderstep 1 - Step 1 — Central HINTS pattern → escalate to neuro.ischaemic-stroke.v1 pathway (tPA / thrombectomy / BP / antiplatelet) (Kattah Stroke 2009 PMID 19762709; AHA/ASA 2026)
Selected step "Step 1 — Central HINTS pattern → escalate to neuro.ischaemic-stroke.v1 pathway (tPA / thrombectomy / BP / antiplatelet) (Kattah Stroke 2009 PMID 19762709; AHA/ASA 2026)" — Any central HINTS feature (normal HIT OR direction-changing nystagmus OR skew) OR HINTS-plus positive (sudden SNHL) OR red flag (severe headache/neck pain, posterior TIA features)

outpatient playbook — drug actions (2)

  1. 1. methylprednisolone or prednisone taper
    rxcui 6902
    Continue Strupp taper to completion (22 d) or US-equivalent prednisone 60 mg → taper × 10-14 d • PO • daily
    trigger: Vestibular neuritis in steroid course initiated in ED
    Complete taper without abrupt discontinuation (Strupp NEJM 2004 PMID 15269315)
  2. 2. meclizine
    rxcui 6676
    STOP if still being used >5 d • PO • discontinue
    trigger: Outpatient follow-up beyond 5 d
    Stop chronic vestibular suppressants to allow compensation (Hotson/Baloh NEJM 1998 PMID 9725927; GRACE-3 PMID 37166022)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Continuous vertigo + nausea/vomiting + gait unsteadiness + nystagmus × ≥24 h (AVS definition; Hotson/Baloh NEJM 1998 PMID 9725927; Tarnutzer CMAJ 2011 PMID 21576300); Acute new vertigo in patient with vascular risk factors (age>60, HTN, DM, smoking, AF, anticoag) — posterior-circulation stroke risk (Kattah Stroke 2009 PMID 19762709); Vertigo + sudden sensorineural hearing loss — AICA-territory stroke until proven otherwise; HINTS-plus pivot (Newman-Toker Acad Emerg Med 2013 PMID 24127701).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Acute Vestibular Syndrome (HINTS pivot for central vs peripheral)** (neuro.acute-vestibular-syndrome.v1).
Phenotype framing: AVS vs BPPV (positional, brief) vs vestibular migraine (recurrent episodic, headache history, photophobia) vs Meniere (episodic + low-tone SNHL + tinnitus) vs Wernicke (thiamine empirically) vs MS / cerebellitis vs functional (PPPD) — episodic vs continuous-with-nystagmus is the key tempo split (Tarnutzer CMAJ 2011 PMID 21576300; Hotson/Baloh NEJM 1998 PMID 9725927)
Scope: Differentiate posterior-circulation stroke from vestibular neuritis in continuous-vertigo-with-nystagmus patient; CT misses ~80% of acute posterior strokes — HINTS is the diagnostic battery (Kattah Stroke 2009 PMID 19762709)

No severity triggers fired against current inputs.

Plan

Regimen axis: **AVS treatment ladder: vestibular neuritis steroids + symptom control + vestibular rehab + Wernicke rescue + BPPV / Meniere arms (Strupp NEJM 2004 PMID 15269315; GRACE-3 PMID 37166022)** — step "Step 1 — Central HINTS pattern → escalate to neuro.ischaemic-stroke.v1 pathway (tPA / thrombectomy / BP / antiplatelet) (Kattah Stroke 2009 PMID 19762709; AHA/ASA 2026)".

Setting playbook (outpatient) — Confirm vestibular neuritis recovery, complete steroid taper, optimise vestibular rehab, screen for vestibular migraine / Meniere if recurrent, audiogram if hearing loss, fall-risk in elderly (Strupp NEJM 2004 PMID 15269315; GRACE-3 PMID 37166022)
1. methylprednisolone or prednisone taper Continue Strupp taper to completion (22 d) or US-equivalent prednisone 60 mg → taper × 10-14 d PO daily — Vestibular neuritis in steroid course initiated in ED (Complete taper without abrupt discontinuation (Strupp NEJM 2004 PMID 15269315))
2. meclizine STOP if still being used >5 d PO discontinue — Outpatient follow-up beyond 5 d (Stop chronic vestibular suppressants to allow compensation (Hotson/Baloh NEJM 1998 PMID 9725927; GRACE-3 PMID 37166022))

Non-pharmacologic actions:
- Vestibular rehabilitation 2-3× / wk for 4-6 wk minimum (Strupp NEJM 2004 PMID 15269315)
- ENT / neurotology referral if persistent vertigo or hearing loss at 4-6 wk
- Neurology referral if recurrent episodic vertigo with migraine features (vestibular migraine pathway)
- Fall-prevention + home modification in elderly
- Driving abstention until vestibular compensation confirmed per jurisdiction

AVOID / contraindication checks:
- No_chronic_vestibular_suppressant_use_delays_central_compensation (Hotson/Baloh NEJM 1998 PMID 9725927)
- No_meclizine_or_benzo_if_falls_risk_elderly_or_dementia (GRACE 3 PMID 37166022)
- No_glucose_before_thiamine_if_Wernicke_suspected
- No_high_dose_steroid_if_active_systemic_infection_or_uncontrolled_diabetes (Strupp NEJM 2004 PMID 15269315)
- No_betahistine_with_concurrent_oral_H1_antihistamines_pharmacologic_antagonism
- No_prochlorperazine_if_QT_prolongation_or_Parkinson_disease
- Never_treat_AVS_as_peripheral_if_HINTS_central_or_uninterpretable_or_HINTS_plus_positive (Kattah Stroke 2009 PMID 19762709; Newman Toker Acad Emerg Med 2013 PMID 24127701)
- Never_rely_on_non_contrast_CT_alone_to_exclude_posterior_circulation_stroke_sensitivity_~20pct (GRACE 3 PMID 37166022 explicit recommendation against CT)

Monitoring

Regimen monitoring:
- symptom trajectory check at 48 72h for outpatient vestibular neuritis (GRACE-3 PMID 37166022)
- audiogram if any hearing involvement at 2 4 wk (Newman-Toker Acad Emerg Med 2013 PMID 24127701)
- vestibular rehab progress at 2 4 wk
- fasting glucose or HbA1c if short course steroid in diabetic (Strupp NEJM 2004 PMID 15269315)
- fall risk assessment in patient >=65

Setting (outpatient) monitoring:
- Clinic visit at 2 wk and 4-6 wk (Strupp NEJM 2004 PMID 15269315)
- Audiogram at 2-4 wk if hearing involvement (Newman-Toker Acad Emerg Med 2013 PMID 24127701)
- Glucose / HbA1c at 4 wk if diabetic on steroid course

Follow-up plan: Vestibular-rehab 4-6 wk; ENT for persistent vertigo / hearing loss / Meniere features; neurology for recurrent vertigo with red flags / migraine features / suspected demyelination; fall-risk assessment + home-safety in elderly; driving counselling per jurisdiction (GRACE-3 PMID 37166022; Hotson/Baloh NEJM 1998 PMID 9725927)
- Close-out criterion: Long-term follow-up scheduled

Monitoring phase: Inpatient (if central): daily neuro-checks + NIHSS; outpatient (if peripheral): symptom-trajectory check at 48-72 h; ENT / audiology if hearing involvement; vestibular-rehab adherence (Strupp NEJM 2004 PMID 15269315; GRACE-3 PMID 37166022)

Disposition

Current setting: outpatient — Confirm vestibular neuritis recovery, complete steroid taper, optimise vestibular rehab, screen for vestibular migraine / Meniere if recurrent, audiogram if hearing loss, fall-risk in elderly (Strupp NEJM 2004 PMID 15269315; GRACE-3 PMID 37166022)

Disposition criteria:
- Discharge from neurology / ENT if symptom resolution + vestibular-rehab complete + audiogram normal
- Long-term ENT if Meniere features develop
- Long-term neurology if vestibular migraine confirmed

Escalation triggers (move to higher acuity):
- Failure to improve by 4-6 wk → ENT / neurotology + MRI internal-auditory canal (rule out vestibular schwannoma)
- New SNHL or recurrent vertigo → audiogram + neurotology
- PHQ-9 ≥10 or persistent dizziness >3 mo → PPPD diagnosis + CBT-vestibular
- Any new focal neuro deficit → ED + stroke pathway

Patient Action Plan

**Acute Vestibular Syndrome / vestibular neuritis recovery action plan**
Personalised values: steroid_taper_schedule, vestibular_rehab_start_date, audiogram_date_if_needed, driving_restriction_status.

**Doing well — recovering** (green):
Triggers:
- steady_improvement_each_day
- no_new_neuro_symptoms
- completing_steroid_taper
- vestibular_rehab_engaged
Actions:
- Continue steroid taper as prescribed; do not stop abruptly
- Attend vestibular rehab — keep doing exercises even when dizzy
- Stop the meclizine / antihistamine when no longer severely vertiginous (>3-5 d delays recovery)
- No driving until medically cleared

**Caution — call ENT / neurology / primary same day** (yellow):
Triggers:
- no_improvement_at_48_72h
- new_hearing_loss_or_tinnitus
- recurrent_vertigo_episodes
- persistent_imbalance_>2wk
- glucose_>200_on_steroid
Actions:
- Call ENT / neurology clinic same day
- Continue medications as prescribed unless told otherwise
- Schedule an audiogram if any hearing change

**Emergency — call 911 / go to ED** (red):
Triggers:
- new_weakness_or_numbness_face_arm_leg
- new_speech_problem_or_difficulty_swallowing
- new_double_vision_or_vision_loss
- sudden_complete_hearing_loss
- worst_ever_headache_or_neck_pain
- loss_of_consciousness_or_drop_attack
Actions:
- Call 911 / go to nearest ED
- This may be a stroke even if you were told it was vestibular neuritis
- Bring medication list
Contact provider when:
- After any ED visit so neurology / ENT can update plan

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Any central HINTS feature: normal head impulse OR direction-changing nystagmus OR skew deviation positive (Kattah Stroke 2009 PMID 19762709)
- [LIFE_THREATENING] Sudden sensorineural hearing loss + AVS — AICA-territory stroke pivot (Newman-Toker Acad Emerg Med 2013 PMID 24127701)
- [SEVERE] Severe occipital headache or neck pain + AVS — vertebral artery dissection trigger (GRACE-3 PMID 37166022)

Citations

- 2023 SAEM GRACE-3 (Edlow et al, Acad Emerg Med) + Kattah HINTS (Stroke 2009) + Newman-Toker HINTS-plus (Acad Emerg Med 2013) + Strupp methylprednisolone (NEJM 2004) [PMID:19762709](https://pubmed.ncbi.nlm.nih.gov/19762709/)
- Cited evidence (PMID 21576300) [PMID:21576300](https://pubmed.ncbi.nlm.nih.gov/21576300/)
- Cited evidence (PMID 24127701) [PMID:24127701](https://pubmed.ncbi.nlm.nih.gov/24127701/)
- Cited evidence (PMID 29163350) [PMID:29163350](https://pubmed.ncbi.nlm.nih.gov/29163350/)
- Cited evidence (PMID 37166022) [PMID:37166022](https://pubmed.ncbi.nlm.nih.gov/37166022/)

Last reconciled with current guidelines: 2026-05-26.
References
  • 2023 SAEM GRACE-3 (Edlow et al, Acad Emerg Med) + Kattah HINTS (Stroke 2009) + Newman-Toker HINTS-plus (Acad Emerg Med 2013) + Strupp methylprednisolone (NEJM 2004) — PMID:19762709
  • Cited evidence (PMID 21576300) — PMID:21576300
  • Cited evidence (PMID 24127701) — PMID:24127701
  • Cited evidence (PMID 29163350) — PMID:29163350
  • Cited evidence (PMID 37166022) — PMID:37166022