Urgent considerations

See Differentials for more details

Stroke

Cerebellar hemorrhage or infarction may lead to herniation and are neurosurgical emergencies. Acute brainstem strokes need to be evaluated for vertebrobasilar dissection or atherosclerosis. Thrombolytic therapy should be considered in cases of nonhemorrhagic brainstem or cerebellar infarction. When bulbar involvement occurs, measures should be taken to avoid aspiration and respiratory failure.

Cerebellar or brainstem infarction present with a sudden onset of symptoms and may be misdiagnosed as vestibular neuritis in patients presenting with acute dizziness or balance difficulty and a high index of suspicion must be maintained to avoid missing these serious and potentially life-threatening neurologic causes. Sudden hearing loss may indicate posterior cerebral circulation ischemia.[34]

The HINTS (Head-Impulse, Nystagmus, Test of Skew deviation) 3-step oculomotor exam helps in diagnosing stroke in patients presenting with acute vestibular syndrome.[35]​ HINTS Plus exams also include an auditory function assessment. The HINTS and HINTS Plus exams appear to be more sensitive for stroke than early MRI.[36][37]​​

Wernicke encephalopathy

Wernicke encephalopathy needs to be considered when acute ataxia is associated with altered level of consciousness, ophthalmoplegia, and nystagmus.[38] People with alcohol dependence, people with gastric disorders (e.g., chronic gastritis), and those experiencing recurring vomiting (e.g., hyperemesis gravidarum) are at risk of developing Wernicke encephalopathy. Unless treated as an emergency with thiamine replacement parenterally, permanent neurologic injury may occur.[13]

Guillain-Barre syndrome (polyradiculoneuropathy, Miller Fisher syndrome)

Acute inflammatory demyelinating radiculoneuropathy that may result in rapidly progressive ascending paralysis and respiratory failure. However, paralysis occurs much less commonly with the Miller Fisher variant.[30]

Spinal cord compression

Urgent neurosurgical management is needed with spinal cord compression to minimize permanent loss of neurologic function.

Meningitis

Peripheral vestibular loss may occur as a complication of meningitis. Occurs acutely and remains as a sequela.

Autoimmune inner ear disease

Urgent immunosuppression is needed to prevent permanent bilateral hearing loss and peripheral vestibular loss (in addition to corneal involvement and complications from systemic vasculitis in cases of Cogan syndrome).[15]

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