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Misleading signs in acute vertigo
  1. Sean Lance,
  2. Stuart Scott Mossman
  1. Department of Neurology, Wellington Hospital, Wellington, New Zealand
  1. Correspondence to Dr Sean Lance, Department of Neurology, Wellington Hospital, Wellington 6021, New Zealand; Sean.Lance{at}


The acute vestibular syndrome is common and usually has a benign cause. Sometimes, however, even experienced neurologists can find it difficult to determine the cause clinically. Furthermore, neuroimaging is known to be insensitive.

We describe two cases of acute vestibular syndrome where conflicting clinical findings contributed to a delay in making the correct diagnosis. The first patient with symptomatic vertigo had signs consistent with horizontal benign paroxysmal positional vertigo but also had an abnormal horizontal head impulse test, superficially suggesting acute vestibular neuritis but later accounted for by the finding of a vestibular schwannoma (acoustic neuroma). The second patient also had an abnormal horizontal head impulse test, with skew deviation suggesting stroke as the cause. However, later assessment identified that a long-standing fourth nerve palsy was the true cause for her apparent skew. We discuss potential errors that can arise when assessing such patients and highlight ways to avoid them.

  • vertigo
  • confirmation bias
  • head impulse test
  • video oculography
  • skew deviation

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  • Contributors Both authors contributed equally to the article.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed. This paper was reviewed by Adolfo Bronstein, London, UK.

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