What's the diagnosis? By Dr. Angela Ugorets

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


  • 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)


  • 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