Approaching Acute Vertigo With Diplopia: A Rare Skew Deviation in Vestibular Neuritis

Abstract

Evaluating the patient with acute constant vertigo or diplopia can be a daunting task for clinicians, who recognize that such symptoms can be the manifestation of potentially devastating disorders like stroke but may be uncomfortable eliciting and interpreting the key symptoms and subtle signs that distinguish dangerous from benign causes. We present a novel and highly instructive case of a patient with acute vertigo and binocular diplopia from a large skew deviation due to vestibular neuritis. As the case unfolds, text and video commentary guide the clinician through the important elements of the history, bedside examination, and laboratory evaluation necessary for accurate diagnosis in the acute vestibular syndrome. We demonstrate how to interpret nystagmus and properly perform the head impulse test and test of skew deviation and discuss the pitfalls of overreliance on imaging when evaluating patients with acute vertigo.

Keywords: AICA, anterior inferior cerebellar artery; AVS, acute vestibular syndrome; BPPV, benign paroxysmal positional vertigo; CT, computed tomography; DWI, diffusion-weighted imaging; HINTS, head impulse, nystagmus, and test of skew; HIT, head impulse test; MRI, magnetic resonance imaging; OTR, ocular tilt reaction; SCC, semicircular canal; SVN, superior vestibular nerve; VEMP, vestibular evoked myogenic potential; VN, vestibular neuritis; VOR, vestibulo-ocular reflex.