Vestibular Localization
Vertigo and vestibular localizer
Teach dizziness through timing, triggers, hearing clues, gait burden, and the eye-movement exam. The goal is to separate canal, labyrinth, vestibular-nerve, stroke, and migraine-network syndromes without collapsing every spinning complaint into one bucket.
Syndrome presets
Start from the bedside vertigo grammar
Students remember vertigo best when you organize it by temporal pattern: continuous acute vestibular syndrome, brief triggered spells, recurrent cochlear episodes, and visually loaded migraine attacks.
Oculomotor trace
Eye-movement pattern under the current syndrome
Unidirectional horizontal-torsional nystagmus that intensifies when gazing in the fast-phase direction.
Duration ladder
Timing usually beats buzzwords
Continuous for 1 to 3 days before compensation starts easing it. Usually one prolonged attack rather than many tiny bursts.
Gaze loading
Does the beat direction stay loyal?
Peripheral syndromes often intensify in one gaze direction. Central syndromes change direction or lose that clean pattern.
Provocation map
What makes the vertigo declare itself
Timing and triggers are often more localizing than the word dizziness itself.
Phenotype
Vestibular neuritis
Continuous hours-to-days vertigo with nausea, unidirectional horizontal-torsional nystagmus, an abnormal head impulse, and no meaningful cochlear symptoms.
Central risk
16%
Not a diagnostic score, but a teaching shorthand for how hard the bedside data pull you toward brainstem-cerebellar causes.
Fixation suppression
78%
Peripheral nystagmus tends to calm when the patient fixates. Central patterns usually ignore that brake.
Gait burden
58%
The more catastrophic the truncal instability, the more you should worry about posterior fossa localization.
Hearing shift
6%
Cochlear symptoms are major localization clues in labyrinthine disease and selected AICA lesions.
Vestibular pathway
Where the lesion pressure sits
Peripheral vestibular apparatus, usually the superior vestibular nerve on one side.
HINTS readout
What the exam is really saying
Head impulse
Positive to the injured side with a corrective catch-up saccade.
Nystagmus
Unidirectional horizontal-torsional nystagmus that intensifies when gazing in the fast-phase direction.
Test of skew
Absent.
One labyrinth suddenly under-fires, so the brain interprets the asymmetry as ongoing head rotation. That creates a slow-phase drift toward the injured side and quick phases away from it.
Differential pivots
What should win and what should lose
Posterior circulation stroke becomes weaker when HINTS stays peripheral and hearing is preserved, but central red flags still win if the gait is severely truncal or focal deficits appear.
Trigger pattern
Head turns worsen the illusion, but the patient is still dizzy at rest.
Hearing frame
Hearing is typically preserved, which separates it from cochlear syndromes.
Bedside maneuvers
Examinations that actually settle the syndrome
HINTS exam
Positive head impulse, unidirectional nystagmus, and no skew pull the syndrome toward the ear rather than the brainstem.
This is the pattern where HINTS helps you avoid reflexively overcalling stroke in a continuously dizzy patient.
Hearing screen
Finger rub and tuning-fork testing are usually symmetric.
Spared hearing supports vestibular neuritis over labyrinthitis or AICA territory ischemia.
Gait check
The patient feels awful and may veer, but can usually still stand or walk with support.
Catastrophic truncal collapse is more worrisome for cerebellar stroke than for isolated neuritis.
Supportive teaching
How to frame the syndrome for learners and patients
- Keep the first explanation simple: one inner ear is under-signaling, so the brain thinks the head is still moving.
- After the hyperacute phase, encourage gentle head movement and visual fixation tasks so central compensation can start.
- Avoid reinforcing bed rest longer than necessary once the dangerous central mimics are excluded.
Continue the loop
Pair vestibular reasoning with anatomy, stroke, gait, and tutoring
Cranial Nerves Explorer
Clinical neurological examination
Stroke Vascular Territories
Acute neurovascular localization
Gait Pattern Localizer
Bedside gait localization
Brain Atlas
Post-clinical anatomical convergence
Neuro Tutor
Cross-module consult reasoning with explicit scoring