Management of Vertigo with Negative Head Impulse, Left Nystagmus, and Negative Dix-Hallpike

Understanding the Clinical Presentation

A negative head impulse test in the setting of acute vertigo suggests intact vestibulo-ocular reflex, pointing toward central pathology, according to the American College of Radiology 1
The presence of spontaneous nystagmus without the characteristic pattern of BPPV raises concern for central causes, as stated by the American Academy of Otolaryngology-Head and Neck Surgery 2
A negative Dix-Hallpike test rules out posterior canal BPPV as the primary diagnosis, but has a negative predictive value of only 52% in primary care settings, as reported by the American Academy of Otolaryngology-Head and Neck Surgery 2, 3

The American Academy of Otolaryngology-Head and Neck Surgery recommends performing a supine roll test to evaluate for lateral semicircular canal BPPV when the Dix-Hallpike test is negative but symptoms suggest BPPV 4, 5
Position the patient supine with head neutral, then quickly rotate the head 90 degrees to each side, and observe for horizontal nystagmus, as described by the American Academy of Otolaryngology-Head and Neck Surgery 5

The American College of Radiology recommends MRI of the brain as the preferred imaging modality for evaluating suspected central causes of vertigo 1
MRI detected acute brain lesions in 11% of patients with episodic vertigo and negative/atypical Dix-Hallpike testing, compared to only 6% with CT, according to the American College of Radiology 1

The American Academy of Otolaryngology-Head and Neck Surgery advises against assuming BPPV is ruled out with a single negative Dix-Hallpike, as the test may need to be repeated at a separate visit due to its 52% negative predictive value 2, 3
The American Academy of Otolaryngology-Head and Neck Surgery recommends against missing lateral canal BPPV, and advises always performing the supine roll test when Dix-Hallpike is negative but clinical suspicion remains 4, 5
The American College of Radiology warns against delaying imaging in atypical presentations, as the combination of spontaneous nystagmus with negative positional testing warrants urgent evaluation for central causes 1