A 64 yo female c/o dizziness.  She has an unsteady gait.  Imaging is done.  What's the diagnosis?  Scroll down for answer.

Answer:  Cerebellar tumor (in this case metastatic)

Red flags for central vertigo

History

• Prolonged symptoms
• Symptoms at rest
• Acute neck pain or recent neck hyperextension (think vertebral artery dissection)
• Stroke risk factors (hypertension, diabetes, somking, vascular disease)
• Cancer (think metastatic disease)

Physical

• Unable to walk
• Bidirectional, rotary, or vertical nystagmus
• HINTS exam positive (positive Head Impulse test, rotary vertical or bidirectional Nystagmus, and positive Test of Scew), click here to read about HINTS
• Other neurological abnormalities (diplopia, dysarthria, numbness, weakness), DO A FULL NEURO EXAM

Imaging for central vertigo

• MRI of brain is more sensitive than CT for posterior fossa (but CT may assist to evaluate for hemorrhage)
• MRI can be falsely negative (12-18%) in first 48 hours (when done correctly, HINTS shown to be 100% sensitive, 96% specific for central etiology)

Signs and symptoms suggesting peripheral etiology of vertigo

• Intermittent / brief episodes of vertigo
• Clear patter of provocation (eg. turning head)
• Horizontal, unidirectional nystagmus
• Ear fullness, deafness, tinnitus
• Photophobia, phonophobia aura (think migrainous)
• Family history of peripheral vertigo

References:

https://www.ahajournals.org/doi/full/10.1161/strokeaha.109.551234

https://www.annemergmed.com/article/S0196-0644(17)31795-X/fulltext

https://www.uptodate.com/contents/evaluation-of-the-patient-with-vertigo