Clinical and radiological diagnostic algorithm for acute vestibular syndrome
https://doi.org/10.14412/2074-2711-2026-2-4-10
Abstract
Acute vestibular syndrome (AVS) is a common reason for seeking emergency care. In real-world clinical practice, patients with AVS are at high risk of delayed diagnosis of both stroke and vestibular neuritis, which has adverse clinical consequences. Among the clinical signs, the most valuable are the characteristics of nystagmus, the results of the Halmagyi head impulse test and the test of ocular lateral deviation, as well as postural function and hearing. Radiological features that facilitate diagnosis include radiological eye deviation, calcification in the projection of the vertebral or basilar artery, and the presence of stenosis or occlusion of these arteries on computed tomography angiography. Magnetic resonance imaging of the brain with thin-slice diffusion-weighted imaging is the optimal modality for visualizing cerebral infarction in patients with central AVS. The quality of differential diagnosis in AVS can be improved by using a combined approach, which involves assessing the most informative clinical and radiological features.
Supporting agencies: The investigation has not been sponsored
About the Authors
M. V. Zamergrad
Russian Medical Academy of Continuing Professional Education, Ministry of Health of Russia; N.I. Pirogov Russian National Research Medical University, Ministry of Health of Russia; I.V. Davydovsky City Clinical Hospital, Moscow Healthcare Department
Russian Federation
Competing Interests:
Russian Federation
Maxim Valeyrevich Zamergrad
Department of Neurology with a course of reflexology and manual therapy; Russian Clinical and Research Center of Gerontology
125993; 2/1, Barrikadnaya St., Build. 1; 129226; 16, 1st Leonova St.; 109240; 11/6, Yauzskaya St.; Moscow
Competing Interests:
There are no conflicts of interest. The authors are solely responsible for submitting the final version of the manuscript for publication. All the authors have participated in developing the concept of the article and in writing the manuscript. The final version of the manuscript has been approved by all the authors
A. A. Kulesh
Acad. E.A. Vagner Perm State Medical University, Ministry of Health of Russia; City Clinical Hospital Four
Russian Federation
Competing Interests:
Russian Federation
614990; 26, Petropavlovskaya St.; 614107; 2, KIM St.; Perm
Competing Interests:
There are no conflicts of interest. The authors are solely responsible for submitting the final version of the manuscript for publication. All the authors have participated in developing the concept of the article and in writing the manuscript. The final version of the manuscript has been approved by all the authors
D. A. Demin
Acad. E.A. Vagner Perm State Medical University, Ministry of Health of Russia; Moscow Multidisciplinary Clinical Center “Kommunarka”, Moscow Healthcare Department
Russian Federation
Competing Interests:
Russian Federation
614990; 26, Petropavlovskaya St.; Perm; 108814; 8/3, Sosenskiy Stan St., Kommunarka; Moscow
Competing Interests:
There are no conflicts of interest. The authors are solely responsible for submitting the final version of the manuscript for publication. All the authors have participated in developing the concept of the article and in writing the manuscript. The final version of the manuscript has been approved by all the authors
References
1. Newman-Toker DE, Cannon LM, Stofferahn ME, et al. Imprecision in patient reports of dizziness symptom quality: a cross-sectional study conducted in an acute care setting. Mayo Clin Proc. 2007 Nov;82(11):1329-40. doi: 10.4065/82.11.1329
2. Kulesh AA, Dyomin DA, Guseva AL, et al. Vestibular vertigo in emergency neurology. Russian Neurological Journal. 2021;26(4):50-9 (In Russ.). doi: 10.30629/2658-7947-2021-26-4-50-59
3. Newman-Toker DE, Della Santina CC, Blitz AM. Vertigo and hearing loss. Handb Clin Neurol. 2016;136:905-21. doi: 10.1016/B978-0-444-53486-6.00046-6
4. Newman-Toker DE, Kerber KA, Hsieh YH, et al. HINTS outperforms ABCD2 to screen for stroke in acute continuous vertigo and dizziness. Acad Emerg Med. 2013 Oct;20(10):986-96. doi: 10.1111/acem.12223
5. Gottlieb M, Peksa GD, Carlson JN. Head impulse, nystagmus, and test of skew examination for diagnosing central causes of acute vestibular syndrome. Cochrane Database Syst Rev. 2023 Nov 2;11(11):CD015089. doi: 10.1002/14651858.CD015089.pub2
6. Dmitriew C, Regis A, Bodunde O, et al. Diagnostic Accuracy of the HINTS Exam in an Emergency Department : A Retrospective Chart Review. Acad Emerg Med. 2021 Apr;28(4):387-93. doi: 10.1111/acem.14171
7. Lee H. Audiovestibular loss in anterior inferior cerebellar artery territory infarction: a window to early detection? J Neurol Sci. 2012 Feb 15;313(1-2):153-9. doi: 10.1016/j.jns.2011.08.039
8. Vanni S, Pecci R, Edlow JA, et al. Differential Diagnosis of Vertigo in the Emergency Department: A Prospective Validation Study of the STANDING Algorithm. Front Neurol. 2017 Nov 7;8:590. doi: 10.3389/fneur.2017.00590
9. Martinez C, Wang Z, Zalazar G, et al. Systematic Review and Meta-Analysis of the Diagnostic Accuracy of a Graded Gait and Truncal Instability Rating in Acutely Dizzy and Ataxic Patients. Cerebellum. 2024 Dec;23(6):2244-56. doi: 10.1007/s12311-024-01718-6. Erratum in: Cerebellum. 2024 Dec;23(6):2257. doi: 10.1007/s12311-024-01724-8
10. Cortese E, Rochelle P, Patel F, et al. Integrated diagnostic algorithm for acute vertigo combining TiTrATE, STANDING, and HINTS: a validation study in the emergency department. Sci Rep. 2025 Jul 14;15(1):25403. doi: 10.1038/s41598-025-11007-9
11. Kattah JC, Badihian S, Pula JH, et al. Ocular lateral deviation with brief removal of visual fixation differentiates central from peripheral vestibular syndrome. J Neurol. 2020 Dec;267(12):3763-72. doi: 10.1007/s00415-020-10100-5
12. Shah VP, Oliveira J E Silva L, et al. Diagnostic accuracy of neuroimaging in emergency department patients with acute vertigo or dizziness : A systematic review and meta-analysis for the guidelines for reasonable and appropriate care in the emergency department. Acad Emerg Med. 2023 May;30(5):517-30. doi: 10.1111/acem.14561
13. Gökcal E, Niftaliyev E, Özdemir T, et al. The association of vertebrobasilar calcification with etiological subtypes, stroke recurrence and outcome in acute brainstem ischemic stroke. Neurol Neurochir Pol. 2018 Mar;52(2):188-93. doi: 10.1016/j.pjnns.2017.09.010
14. Hiremath SB, Erdenebold UE, Kontolemos M, et al. Association between vascular calcification in intracranial vertebrobasilar circulation and luminal stenosis. Neuroradiology. 2022 Dec;64(12):2285-93. doi: 10.1007/s00234-022-02974-1
15. Kulesh AA, Demin DA. Wallenberg–Zakharchenko syndrome in vascular neurology emergency care : A review. Consilium Medicum. 2024;26(11):711-8 (In Russ.). doi: 10.26442/20751753.2024.11.203020
16. Badihian S, Samaha E, Newman-Toker DE, et al. Radiographic Horizontal Conjugate Gaze Deviation: Clinical Correlates. Neurol Clin Pract. 2025 Feb;15(1):e200375. doi: 10.1212/CPJ.0000000000200375
17. Teufel J, Strupp M, Linn J, et al. Conjugate Eye Deviation in Unilateral Lateral Medullary Infarction. J Clin Neurol. 2019 Apr;15(2):228-34. doi: 10.3988/jcn.2019.15.2.228
18. Farhat R, Awad AA, Shaheen WA, et al. The “Vestibular Eye Sign” – “VES”: a new radiological sign of vestibular neuronitis can help to determine the affected vestibule and support the diagnosis. J Neurol. 2023 Sep;270(9):4360-7. doi: 10.1007/s00415-023-11771-6
19. Spiegelberg M, Morel C, Beer JH, et al. Ocular Lateral Deviation in Severe Gait Imbalance Pointing to Lateral Medullary Stroke. Neurohospitalist. 2021 Oct;11(4):375-6. doi: 10.1177/19418744211000953
20. Kim JS, Newman-Toker DE, Kerber KA, et al. Vascular vertigo and dizziness: Diagnostic criteria. J Vestib Res. 2022;32(3):205-22. doi: 10.3233/VES-210169
21. Du EH, Tenenbaum MN, Bhadelia RA, et al. Major radiological outcomes of CTA head and neck performed for dizziness in a major academic Emergency Department. Neuroradiol J. 2023 Jun;36(3):259-66. doi: 10.1177/19714009221124304
22. Kulesh AA, Demin DA, Vinogradov OI. Cervical dissection in emergency neurology: diagnostic and treatment algorithms. Russian Neurological Journal. 2022;27(4):86-96 (In Russ.). doi: 10.30629/2658-7947-2022-27-4-86-96
23. Choi JH, Oh EH, Park MG, et al. Early MRI-negative posterior circulation stroke presenting as acute dizziness. J Neurol. 2018 Dec;265(12):2993-3000. doi: 10.1007/s00415-018-9097-z
24. Axer H, Grässel D, Brämer D, et al. Time course of diffusion imaging in acute brainstem infarcts. J Magn Reson Imaging. 2007 Oct;26(4):905-12. doi: 10.1002/jmri.21088
25. Lozano RJ, Shareef F, Neupane A, et al. Detectability of acute ischemic stroke with thin (3 mm) axial versus thin (3 mm) coronal diffusion-weighted imaging in patients presenting to the emergency department with acute dizziness. Emerg Radiol. 2025 Apr;32(2):225-31. doi: 10.1007/s10140-025-02327-4
26. Tu LH, Navaratnam D, Melnick ER, et al. CT With CTA Versus MRI in Patients Presenting to the Emergency Department With Dizziness: Analysis Using Propensity Score Matching. AJR Am J Roentgenol. 2023 Dec;221(6):836-45. doi: 10.2214/AJR.23.29617
27. Tu LH, Melnick E, Venkatesh AK, et al. Cost-Effectiveness of CT, CTA, MRI, and Specialized MRI for Evaluation of Patients Presenting to the Emergency Department With Dizziness. AJR Am J Roentgenol. 2024 Feb;222(2):e2330060. doi: 10.2214/AJR.23.30060
28. Shareef F, Tu L, Neupane A, et al. Diagnostic yield of an abbreviated MRI protocol in the evaluation of dizziness in the emergency department, a single institutional experience. Emerg Radiol. 2025 Aug;32(4):559-68. doi: 10.1007/s10140-025-02349-y
29. Monak AA, Kaileva NA, Kulesh AA, et al. Labyrinthine infarction as a cause of acute cochleovestibular syndrome. Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2023;15(1):71-6 (In Russ.). doi: 10.14412/2074-2711-2023-1-71-76
Review
For citations:
Zamergrad MV, Kulesh AA, Demin DA. Clinical and radiological diagnostic algorithm for acute vestibular syndrome. Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2026;18(2):4-10. (In Russ.) https://doi.org/10.14412/2074-2711-2026-2-4-10
Views:
1277
JATS XML
Email this article 