Clinical Analysis: Vertigo + BP 180/100 + No Hearing Loss + Normal CT/MRI

Key Features to Anchor the Differential

Most Likely Diagnoses

1. Benign Paroxysmal Positional Vertigo (BPPV) - Most Common Overall

• Brief episodes triggered by head position changes (turning in bed, looking up)
• No hearing loss, no tinnitus
• Normal imaging (expected)
• High BP is incidental - it does not cause or exclude BPPV
• Diagnosis confirmed by a positive Dix-Hallpike test showing upbeat/torsional nystagmus that fatigues with repeated testing
• Treated with the Epley maneuver

"Episodic vertigo produced primarily by a change in head position and lasting less than a minute suggests BPPV." - Rosen's Emergency Medicine

2. Vestibular Neuritis - Most Likely if Vertigo is Continuous

• Sudden onset of sustained vertigo lasting days, with nausea and vomiting
• No hearing loss (this is the key distinguishing feature from labyrinthitis)
• Normal MRI (expected - the inflammation of the vestibular nerve is not visible on standard MRI)
• Often follows a viral illness
• Positive head impulse test (corrective saccade)
• The HINTS exam (Head Impulse, Nystagmus, Test of Skew) at the bedside reliably distinguishes this from a central stroke even with normal MRI

"Labyrinthitis is differentiated from vestibular neuritis in that the former is associated with hearing loss due to inflammation of both the vestibular and cochlear components of the eighth CN." - Rosen's Emergency Medicine

3. Vertebrobasilar Insufficiency (VBI) / TIA - Must Exclude Given High BP

• Abrupt onset vertigo, usually lasting several minutes
• Patient has a major risk factor: hypertension (180/100)
• This is the most dangerous diagnosis to miss
• Normal MRI does NOT fully exclude TIA (small perforator infarcts can be MRI-negative early)
• Other VBI features to look for: diplopia, dysarthria, dysphagia, ataxia, drop attacks, facial numbness
• If isolated vertigo with no other posterior circulation symptoms: VBI is less likely, but remains in the differential given uncontrolled hypertension

"Vertebrobasilar insufficiency is a significant cause of vertigo in the elderly population. Vertigo due to vertebrobasilar insufficiency has abrupt onset, usually lasts several minutes, and is frequently associated with nausea and vomiting." - Cummings Otolaryngology

4. Vestibular Migraine

• Recurrent episodic vertigo, can last minutes to hours
• No mandatory hearing loss
• Normal imaging
• Headache may or may not accompany each episode
• Diagnosed by history (personal/family history of migraine)

Role of Hypertension (180/100) in This Case

• High BP is not a direct cause of vertigo in most cases. The old teaching that "hypertension causes vertigo" is largely incorrect.
• However, uncontrolled hypertension is a major vascular risk factor that raises suspicion for vertebrobasilar ischemia or TIA.
• Hypertension can also worsen or precipitate Meniere's disease in susceptible individuals, but the absence of hearing loss argues against this.
• Always treat the BP regardless of the vertigo etiology.

Practical Diagnostic Approach

1. Perform the Dix-Hallpike test at the bedside - if positive with fatigable torsional/upbeat nystagmus → BPPV, treat with Epley maneuver
2. HINTS exam if the patient has acute vestibular syndrome (continuous vertigo): Head Impulse test + Nystagmus direction + Test of Skew
   • Peripheral pattern (positive HIT + unidirectional nystagmus + no skew) → Vestibular neuritis
   • Central pattern (negative HIT or direction-changing nystagmus or skew) → Posterior circulation event, even if MRI is normal
3. Look for other posterior circulation signs: diplopia, dysarthria, dysphagia, limb ataxia, Horner syndrome - if any are present, treat as stroke until proven otherwise
4. MRI with DWI is preferred over CT for posterior fossa pathology, but early DWI can be falsely negative in the first 24-48 hours for small brainstem infarcts. Repeat MRI at 48-72 hours if clinical suspicion remains

Summary Table