A 72-year-old man presents with sudden onset of severe dizziness with associated nausea and vomiting two hours ago. On exam, there is vertical nystagmus with vertical gaze and horizontal nystagmus with horizontal gaze, and he has an unsteady gait. Which of the following is the most likely cause of these symptoms?

A 72-year-old man presents with sudden onset of severe dizziness with associated nausea and vomiting two hours ago. On exam, there is vertical nystagmus with vertical gaze and horizontal nystagmus with horizontal gaze, and he has an unsteady gait. Which of the following is the most likely cause of these symptoms?

• A. Vestibular neuritis
• B. Cerebellar hemorrhage
• C. Meniere disease
• D. Acute labyrinthitis

Answer: (B)

Central vertigo often shows signs that point to a brainstem or cerebellar problem rather than the inner ear. Here, the key clue is the type of nystagmus and the gait disturbance. Vertical nystagmus that changes with gaze, along with an unsteady, uncoordinated gait, suggests a central process affecting the cerebellum or brainstem. In cerebellar hemorrhage, you can see acute vertigo with prominent ataxia and gaze-evoked or direction-changing nystagmus, including vertical components. This pattern stands in contrast to peripheral causes of vertigo, where the nystagmus is typically unidirectional and horizontal (and often fatigues with fixation), and where hearing loss or tinnitus is more characteristic (as in labyrinthitis or Meniere disease). Therefore, the presentation points toward a central lesion like cerebellar hemorrhage rather than a peripheral vestibular disorder. This is a neurosurgical emergency, so urgent imaging is warranted to assess for hemorrhage.

Central vertigo often shows signs that point to a brainstem or cerebellar problem rather than the inner ear. Here, the key clue is the type of nystagmus and the gait disturbance. Vertical nystagmus that changes with gaze, along with an unsteady, uncoordinated gait, suggests a central process affecting the cerebellum or brainstem. In cerebellar hemorrhage, you can see acute vertigo with prominent ataxia and gaze-evoked or direction-changing nystagmus, including vertical components. This pattern stands in contrast to peripheral causes of vertigo, where the nystagmus is typically unidirectional and horizontal (and often fatigues with fixation), and where hearing loss or tinnitus is more characteristic (as in labyrinthitis or Meniere disease).

Therefore, the presentation points toward a central lesion like cerebellar hemorrhage rather than a peripheral vestibular disorder. This is a neurosurgical emergency, so urgent imaging is warranted to assess for hemorrhage.