Evaluation, causes and management of acute spontaneous dizziness


  • Emad A. Subahi Department of Emergency Medicine, Al Noor Specialist Hospital, Mecca, Saudi Arabia
  • Adel Saleh Alanazi Department of Emergency Medicine, King Salman Armed Forces Hospital, Tabuk, Saudi Arabia
  • Laila Khaled Alanazi Department of Internal Medicine, Hera General Hospital, Mecca, Saudi Arabia
  • Mohammed Khalid Alharbi Department of Internal Medicine, Hera General Hospital, Mecca, Saudi Arabia
  • Hussain Ali Bu Shehab College of Medicine, University of Pécs, Pécs, Hungary
  • Fares Abdullah Alnakhli College of Medicine, Shaqra University, Shaqra, Saudi Arabia
  • Maryam Abdullah Tawhari College of Medicine, Princess Nourah Bint Abdul Rahman University, Riyadh, Saudi Arabia
  • Sulaiman Mulfi Alshammari Department of Ophthalmology, King Khalid Hospital, Hail, Saudi Arabia
  • Mohammed Munir Alshahrani Department of Emergency Medicine, King Salman Hospital, Riyadh, Saudi Arabia
  • Abdulmajeed Salem Alfaifi Department of Emergency Medicine, King Salman Hospital, Riyadh, Saudi Arabia
  • Bandar Mohammed Almotairi College of Medicine, Shaqra University, Shaqra, Saudi Arabia




Dizziness, Vertigo, Emergency medicine, Stroke


Although acute dizziness is a very frequent reason for admissions to emergency care, its differential diagnosis is difficult to establish due to many factors. Dizziness may mean diverse sensations such as vertigo, lightheadedness, presyncope, disequilibrium, or simply feeling unwell. The classical approach to dizziness initiates with characterizing the form of dizziness according to the belief that every kind of dizziness represents a particular underlying etiology: vertigo is vestibular, presyncope is cardiovascular, disequilibrium is neurological, and nonspecific dizziness is psychogenic or metabolic. Development of acute dizziness/vertigo unaccompanied by precipitating features occurs in patients of acute spontaneous dizziness. The dizziness/vertigo mainly presents with autonomic symptoms like imbalance, nausea, and vomiting. Dizziness/vertigo and imbalance are the commonest manifestations in vertebrobasilar ischemia, which accounts for over 20% of all ischemic strokes. It is essential to distinguish between isolated vascular vertigo from less severe disorders related to the inner ear as the treatment plan and prognosis vary among these problems. The development of diffusion-weighted magnetic resonance imaging (MRI) has improved the infarction identification in cases with vascular dizziness/vertigo, particularly from undermined posterior blood flow. Nonetheless, proper bedside neurotologic assessment which includes components such as head impulse/thrust test, head shaking nystagmus test and ocular tilt reaction test demonstrate higher sensitivity than imaging in diagnosing acute cerebrovascular accidents as an etiology of abruptly occurring vertigo lasting longer than one day, particularly in the initial 48 hours.



Cappello M, Di Blasi U, Di Piazza L. Dizziness and vertigo in a department of emergency medicine. Eur J Emergency Med. 1995;2(4):201-11.

Baloh RW. Vertigo. Lancet. 1998;352(9143):1841-6.

Zarachi A, Pezoulas V, Lianou A. Dizziness in the Emergency Department: Insights and Epidemiological Data-a Population Based Study. Maedica. 2022;17(1):122-8.

Newman-Toker DE, Cannon LM, Stofferahn ME, Rothman RE, Hsieh Y-H, Zee DS. Imprecision in patient reports of dizziness symptom quality: a cross-sectional study conducted in an acute care setting. Paper presented at: Mayo Clinic Proceedings. 2007.

Drachman DA, Hart CW. An approach to the dizzy patient. Neurology. 1972.

Hanley K, O'Dowd T. Symptoms of vertigo in general practice: a prospective study of diagnosis. Brit J General Pract. 2002;52(483):809-12.

Choi JH, Seo JD, Kim MJ. Vertigo and nystagmus in orthostatic hypotension. Eur J Neurol. 2015;22(4):648-55.

Kim SH, Park SH, Kim HJ, Kim JS. Isolated central vestibular syndrome. Ann NY Academy Sci. 2015;1343(1):80-9.

Savitz SI, Caplan LR. Vertebrobasilar disease. N Eng J Med. 2005;352(25):2618-26.

Paul NL, Simoni M, Rothwell PM. Transient isolated brainstem symptoms preceding posterior circulation stroke: a population-based study. Lancet Neurol. 2013;12(1):65-71.

Choi K-D, Lee H, Kim J-S. Vertigo in brainstem and cerebellar strokes. Curr Opinion Neurol. 2013;26(1):90-5.

Lee H, Sohn S-I, Cho Y-W. Cerebellar infarction presenting isolated vertigo: frequency and vascular topographical patterns. Neurology. 2006;67(7):1178-83.

Kattah JC, Talkad AV, Wang DZ, Hsieh Y-H, Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009;40(11):3504-10.

Newman-Toker DE, Saber Tehrani AS, Mantokoudis Gl. Quantitative video-oculography to help diagnose stroke in acute vertigo and dizziness: toward an ECG for the eyes. Stroke. 2013;44(4):1158-61.

Tehrani ASS, Kattah JC, Mantokoudis G. Small strokes causing severe vertigo: frequency of false-negative MRIs and nonlacunar mechanisms. Neurology. 2014;83(2):169-73.

Baloh RW. Differentiating between peripheral and central causes of vertigo. Otolaryngol-Head Neck Surg. 1998;119(1):55-9.

Lee C-C, Su Y-C, Ho H-C. Risk of stroke in patients hospitalized for isolated vertigo: a four-year follow-up study. Stroke. 2011;42(1):48-52.

Johnston SC, Rothwell PM, Nguyen-Huynh MN. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet. 2007;369(9558):283-92.

Navi BB, Kamel H, Shah MP. Application of the ABCD2 score to identify cerebrovascular causes of dizziness in the emergency department. Stroke. 2012;43(6):1484-9.

Serra A, Leigh R. Diagnostic value of nystagmus: spontaneous and induced ocular oscillations. J Neurol Neurosurg Psychiatr. 2002;73(6):615-8.

Robinson DA, Zee DS, Hain TC, Holmes A, Rosenberg LF. Alexander's law: Its behavior and origin in the human vestibulo‐ocular reflex. Ann Neurol. 1984;16(6):714-22.

Hotson JR, Baloh RW. Acute vestibular syndrome. New England J Med. 1998;339(10):680-685.

Baloh R, Yee R. Spontaneous vertical nystagmus. Revue Neurol. 1989;145(8-9):527-32.

Böhmer A, Straumann D. Pathomechanism of mammalian downbeat nystagmus due to cerebellar lesion: a simple hypothesis. Neurosci Letters. 1998;250(2):127-30.

Baloh RW, Spooner JW. Downbeat nystagmus: a type of central vestibular nystagmus. Neurology. 1981;31(3):304.

Glasauer S, Hoshi M, Kempermann U, Eggert T, Buttner U. Three-dimensional eye position and slow phase velocity in humans with downbeat nystagmus. J Neurophysiol. 2003;89(1):338-54.

Huh Y-E, Kim J-S. Bedside evaluation of dizzy patients. J Clin Neurol. 2013;9(4):203-13.

Choi KD, Oh SY, Kim HJ, Koo JW, Cho BM, Kim JS. Recovery of vestibular imbalances after vestibular neuritis. Laryngoscope. 2007;117(7):1307-12.

Büttner U, Grundei T. Gaze-evoked nystagmus and smooth pursuit deficits: their relationship studied in 52 patients. J Neurol. 1995;242(6):384-9.

Leigh RJ, Zee DS. The neurology of eye movements. Contemporary Neurol. 2015.

Hain T, Fetter M, Zee D. Head-shaking nystagmus in patients with unilateral peripheral vestibular lesions. Am J Otolaryngol. 1987;8(1):36-47.

Weber K, Aw S, Todd M, McGarvie L, Curthoys I, Halmagyi G. Head impulse test in unilateral vestibular loss: vestibulo-ocular reflex and catch-up saccades. Neurology. 2008;70(6):454-63.

Newman-Toker DE, Kattah JC, Alvernia JE, Wang DZ. Normal head impulse test differentiates acute cerebellar strokes from vestibular neuritis. Neurology. 2008;70(24 Part 2):2378-85.

Walker MF, Zee DS. Cerebellar disease alters the axis of the high-acceleration vestibuloocular reflex. J Neurophysiol. 2005;94(5):3417-29.

Walker MF, Zee DS. Directional abnormalities of vestibular and optokinetic responses in cerebellar disease. Ann New York Academy of Sci. 1999;871(1):205-20.

Jeong S-H, Kim J-S, Baek IC. Perverted head impulse test in cerebellar ataxia. Cerebellum. 2013;12(5):773-5.

Brodsky MC, Donahue SP, Vaphiades M, Brandt T. Skew deviation revisited. Survey Ophthalmol. 2006;51(2):105-28.

Smith JL, David NJ, Klintworth G. Skew deviation. Neurology. 1964;14(2):96.

Dieterich M, Brandt T. Ocular torsion and tilt of subjective visual vertical are sensitive brainstem signs. Ann Neurol. 1993;33(3):292-9.

Chalela JA, Kidwell CS, Nentwich LM. Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison. Lancet. 2007;369(9558):293-8.

Oppenheim C, Stanescu R, Dormont D. False-negative diffusion-weighted MR findings in acute ischemic stroke. Am J Neuroradiol. 2000;21(8):1434-40.

Kim JS, Cho K-H, Lee H. Isolated labyrinthine infarction as a harbinger of anterior inferior cerebellar artery territory infarction with normal diffusion-weighted brain MRI. J Neurol Sci. 2009;278(1-2):82-4.

43. Kim DU, Han M-K, Kim JS. Isolated recurrent vertigo from stenotic posterior inferior cerebellar artery. Otol Neurotol. 2011;32(1):180-2.

Grad A, Baloh RW. Vertigo of vascular origin: clinical and electronystagmographic features in 84 cases. Arch Neurol. 1989;46(3):281-4.

Hoshino T, Nagao T, Mizuno S, Shimizu S, Uchiyama S. Transient neurological attack before vertebrobasilar stroke. J Neurolog Sci. 2013;325(1-2):39-42.

Fisher C. Vertigo in cerebrovascular disease. Arch Otolaryngol. 1967;85(5):529-34.

Lee H, Cho Y. Auditory disturbance as a prodrome of anterior inferior cerebellar artery infarction. J Neurol Neurosurg Psychiatr. 2003;74(12):1644-8.

Kim J, Lopez I, DiPatre P, Liu F, Ishiyama A, Baloh RW. Internal auditory artery infarction: clinicopathologic correlation. Neurology. 1999;52(1):40-40.

Kim H-A, Lee S-R, Lee H. Acute peripheral vestibular syndrome of a vascular cause. J Neurological Sci. 2007;254(1-2):99-101.

Kim JS, Lee H. Vertigo due to posterior circulation stroke. Paper presented at: Seminars in Neurol. 2013.

Jackson C, Sudlow C. Comparing risks of death and recurrent vascular events between lacunar and non-lacunar infarction. Brain. 2005;128(11):2507-17.

Jeong S-H, Kim H-J, Kim J-S. Vestibular neuritis. Paper presented at: Seminars in Neurol. 2013.

Fishman JM, Burgess C, Waddell A. Corticosteroids for the treatment of idiopathic acute vestibular dysfunction (vestibular neuritis). Cochrane Database of Systematic Reviews. 2011(5).

Strupp M, Zingler VC, Arbusow V. Methylprednisolone, valacyclovir, or the combination for vestibular neuritis. N Engl J Med. 2004;351(4):354-61.

Strupp M, Arbusow V, Maag K, Gall C, Brandt T. Vestibular exercises improve central vestibulospinal compensation after vestibular neuritis. Neurology. 1998;51(3):838-44.




How to Cite

Subahi, E. A., Alanazi, A. S., Alanazi, L. K., Alharbi, M. K., Shehab, H. A. B., Alnakhli, F. A., Tawhari, M. A., Alshammari, S. M., Alshahrani, M. M., Alfaifi, A. S., & Almotairi, B. M. (2022). Evaluation, causes and management of acute spontaneous dizziness. International Journal Of Community Medicine And Public Health, 9(10), 3942–3947. https://doi.org/10.18203/2394-6040.ijcmph20222589



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