R/O Stroke in Patient w/ Active Vertigo

NOTE  —  THE COMMENTS BELOW ONLY REFER TO A PATIENT WHO HAS ACTIVE VERTIGO & NYSTAGMUS AT THE MOMENT, there in the office (which is pretty uncommon).

One study found 100% sensitivity & 96% specificity for Stroke if any of the following 3 bedside tests were positive (performed on a patient with active vertigo & nystagmus:

  1. Horizontal Head Thrust (the most important)
  2. Direction-Changing Nystagmus with eccentric gaze
  3. Skew
1)  Horizontal Head Thrust (hHT):
  1. Have them focus continuously on a spot straight ahead
  2. Turn their head abruptly to one side
  3. If Labyrinthine disease, response is abnormal: eyes move involuntarily with the head, then dart back to regain focus (bottom pix)
  4. If Stroke, eyes maintain normal focus (top pix)

Clarification:
  • Patients with a peripheral etiology for their vertigo have an abnormal response.
  • Normal persons without illness have a “normal response”
  • Stroke patients also have a “normal response” [some with cerebellar stroke might have an abnormal response].

2)  Direction-Changing Nystagmus with eccentric gaze.

  1. Nystagmus present when staring straight ahead
  2. Ask patient to look to right & then left
  3. If nystagmus starts beating the other way, think Stroke

Watch a brief video!

3)  Skew
  1. Patient focuses continuously straight ahead.
  2. Cover one eye.
  3. Uncover it, and cover the other
  4. Keep repeating
  5. If you see one eye staring off with skewed alignment for a moment when uncovered, think Stroke

Remember  —  All the above tests imply that the patient comes in with active vertigo and nystagmus, which is not too common.

Here’s the whole article, for anyone interested [though it’s all a little obscure]: