An unusual case of vertigo: the usefulness of nystagmus examination

Excerpt

A 50-year-old gardener presented to our Emergency Department (ED) after the onset of a sudden objective vertigo while standing up during work, accompanied by imbalance, nausea, and vomiting. Neither tinnitus nor other aural symptoms were present, but, if asked, he also complained of a mild headache. He had no medical background of interest except for a known hypertension, left untreated, and a possible history of migraine for which he was admitted to the ED 1 year before. He denied recent viral infections or trauma. He was an active smoker (35 pack years), but denied alcohol or sympathomimetic intake; he was not taking any medication and had no allergies. Clinical examination revealed no neurological deficit, in particular neither dysmetria nor motor or sensitive deficit, and the patient’s physical examination was normal except for a right beating horizontal nystagmus in primary position. Due to vomiting and overt vagal signs, upright position was impossible to evaluate. The blood pressure was found high and symmetric in both arms (160/100 mmHg), but the other vital signs were normal (HR 80 beats/min, SpO₂ 99 % in FiO₂ 21 %, temperature 36.5 °C). The National Institutes of Health Stroke Scale (NIHSS) was 0 [1]. The absence of otological and aural symptoms, as well as the absence of a recurrent vertigo in the history of the patient, was not compatible with Menière disease. A vestibular migraine could be excluded too because of the lack of diagnostic criteria of migraine [2]. The patient was free from neurological signs except for nystagmus and referred imbalance. These features could be typical of an acute vestibular syndrome of peripheral origin; however, a more detailed nystagmus evaluation was needed. The STANDING, a recently developed diagnostic algorithm for the evaluation of patients with acute vertigo, was used to evaluate the patient [3] (Fig. 1).

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