The First Attack of Vertigo – Is it a Stroke or is it Inner Ear Disease?

May 06, 2020 - by Preview - in Dizziness

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The First Attack of Vertigo: Is it a Stroke or is it Inner Ear Disease?


If vertigo suddenly occurs, with no pre-existing history of dizziness, then both patient and doctor are concerned whether this represents a transient ischaemic attack (TIA or “mini-stroke”) which may herald the advent of a much more serious stroke with its devastating consequences.


The diagnosis of a TIA/stroke can be reasonably suspected by looking for a combination of symptoms, signs, risk factors & investigations.



If there have been more than 3 vertigo events it is less likely to be a TIA/stroke.

Associated central system symptoms such as double vision, difficulty speaking, swallowing and moving the face or arms and legs suggest a TIA/stroke. If the severe vertigo is for less than 30 minutes, this point towards a TIA/stroke as the cause.


Auditory symptoms such as hearing loss, tinnitus and pain tends to occur with inner ear disease but can occur with a TIA/stroke.



Reduced conscious level, inability to stand unassisted, weakness of the arms, legs and facial weakness that involves the mouth but spares the eye and forehead are clear signs of a stroke, however, more subtle signs can be found on eye examination. In particular a feature called “skew deviation” is looked for and is highly suggestive of a TIA/stroke. Atypical nystagmus is of some concerning significance (e.g. bi-directional nystagmus or down beat nystagmus), however, a normal head impulse test is a weak indicator of a TIA/stroke.


A rash of the outer ear, soft palate and facial weakness involving the mouth, eye and forehead are strong indicators of an inner ear cause.


Risk factors

A more elderly patient with a history of cardiovascular disease is at greater risk of a TIA.



An MRI shows changes consistent with a TIA or stroke however clinical examination has been found be more accurate within 48 hours of the event. MRI changes can take up to 48 hours to appear.




If a TIA/stroke is suspected, then an urgent opinion is needed from a neurologist.









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