For Healthcare Professionals:
In patients with acute vestibular syndrome (AVS), distinguishing between Vestibular neuritis and a stroke (posterior circulation stroke; PCS) is one of the most important tasks in the emergency department. The HINTS test (Head Impulse, Nystagmus, and Test of Skew) has proven to be more sensitive than an early MRI.
🔗 Akdal G, Nham B, Kwok B, et al. Vestibular event monitoring in acute posterior circulation stroke: from emergency room to stroke unit and beyond. J Neurol. 2025;272(8):510. Published 2025 Jul 15. doi:10.1007/s00415-025-13163-4
Study design:
- 80 patients with acute PCS and AVS symptoms (dizziness, imbalance)
- Videonystagmography (VNG) at presentation and up to 9 days thereafter, with a total of 238 recordings
- Observation of whether nystagmus was present at presentation or developed during the course
Key results
- 47/80 patients had nystagmus at presentation (appearing central or peripheral)
- 33/80 patients showed no nystagmus at presentation; 12 of them developed nystagmus during follow-up
- 21/80 patients remained completely free of nystagmus
- The type of nystagmus remained stable, with no shifts between “peripheral” and “central.
Clinical Relevance
- The absence of nystagmus at initial examination does not rule out stroke
- Nystagmus may develop with delay
- Patients require inpatient monitoring with repeated clinical examinations and, if indicated, MRI
- „Absence of evidence is not evidence of absence.“
Conclusion for Practice
The study confirms that HINTS, when performed by physicians, remains indispensable in acute diagnostics. Absence of nystagmus must not be misinterpreted—repeated examinations are essential.
Therapists have their role in the subsequent course: they can comprehensively assess the severity and nature of the vestibular disorder and provide targeted rehabilitation—whether of peripheral or central origin.
👉 Are you interested in a comprehensive further training in vestibular rehabilitation and how vestibular disorders can be differentiated and rehabilitated after the acute phase?
Current further education opportunities can be found in the IVRT Course search.
For Patients – Easy to Understand
Dizziness in the Emergency Department: Why the Absence of Nystagmus Is Not Always Reassuring
Sudden severe dizziness can be caused by a inflammation of the inner ear or by a stroke . A specific test—the HINTS exam—is often more accurate than early MRI in the emergency department.
📄 Akdal G, Nham B, Kwok B, et al. Vestibular event monitoring in acute posterior circulation stroke: from emergency room to stroke unit and beyond. J Neurol. 2025;272(8):510. Published 2025 Jul 15. doi:10.1007/s00415-025-13163-4
What does this mean
- The diagnosis in the initial, severe phase of dizziness must be made exclusively by physicians.
- Nystagmus may arise in both inner ear inflammation and stroke.
- Even if no nystagmus is visible at the beginning, it may still be a stroke.
- Therefore, repeated medical examinations and often an MRI after a few days are necessary.
What role do therapists play in this context?
- After initial medical care, specially trained vestibular therapists take over further assessment.
- They assess the extent to which the balance system is affected.
- They initiate targeted exercise programs for rehabilitation — regardless of whether the cause lies in the inner ear or the brain.
Conclusion
What does this mean for you?
In cases of sudden severe dizziness, the initial assessment and diagnosis must be carried out by physicians. Later, specialized therapists can help patients train their balance and regain confidence in their own movements.
🎯 Our IVRT®-certified dizziness and vestibular therapists, who can support you individually, can be found through our IVRT therapist search