HPI

• 35 year old female with PMHx of Diabetes, OSA p/w 2 hrs of tinnitus and vertigo
• No hx of vertigo, no hearing loss
• No recent URI symptoms
• No substance use

Physical Exam

VS: BP (!) 143/101 | Pulse 90 | Temp 98 °F (36.7 °C) (Oral) | Resp 20 | Ht 1.664 m (5' 5.5") | Wt 107.5 kg (237 lb) | SpO2 94% | BMI 38.84 kg/m²

• Pt in distress, head in hands, vomiting
• Appears somewhat somnolent 
• Head: no obvious abnormalities, ecchymosis or signs of trauma
• Neuro: CN II-XII intact, HINTS exam: +corrective saccade on head impulse test, horizontal nystagmus fast phase to R side, negative test of skew b/l, no ataxia on finger to nose or heel to shin b/l, strength 5/5 UE and LE b/l, no pronator drift b/l, could not participate in Dix-Hallpike due to continuous vomiting 
• Ear: Pinnae, canal and TM clear b/l
• Heart: normal rate and rhythm 
• Pulm: tachypneic, lungs clear
• Abdomen: no tenderness

Initial ED Treatment

• LR bolus, zofran, valium (will not tolerate po meclizine)
• ECG

Differential Diagnosis 

• Likely peripheral vertigo such as BPPV or labyrinthitis or Meniere's disease given HINTS exam findings
• Less likely central vertigo- such as posterior cerebellar CVA, hemorrhage, or tumor given young age, although has a stroke risk factor (DM)
• Less likely acute ear pathology- otitis media or externa based on exam 

Reassessment

• On repeat exam subtle dysmetria with R hand on finger to nose testing noted
•  STAT MRI Brain w/o contrast to rule out suspicion for posterior cerebellar stroke
• MRI Brain showed: Large left superior cerebellar cerebellar nonhemorrhagic infarct. Local mass effect without evidence of hydrocephalus
• CTA showed: Occlusion of the left superior cerebellar artery at its origin, otherwise normal CTA
• Patient asmitted to ICU for BP control, later concern for worsening infarct and increased ICP, requiring emergent EVD placement and later decompressive craniectomy 
• Patient discharged with unsteady gait and deficits in proprioception of L LE

Pearls

• Consider central causes of vertigo in all patients, even those "too young" for posterior circulation CVA or intracranial hemorrahge
• Repeat a careful neurologic exam: pts with peripheral vertigo should have a normal neurologic exam barring horizontal nystagmus
• With a patient’s first case of “vertigo” symptoms- always have posterior cerebellar stroke on your differential!
• Remember patient’s don’t follow the textbook! A young female with sudden onset R ear pain, tinnitus, positional dizziness, and horizontal nystagmus is  peripheral vertigo...until it’s not!