Management of Vertigo with Positive Romberg Test

Clinical Assessment and Diagnosis

The American College of Radiology recommends performing a HINTS examination (Head Impulse, Nystagmus, Test of Skew) if the patient has acute persistent vertigo, as it can help identify central warning signs requiring urgent imaging 1
Central warning signs that require urgent imaging include nystagmus that changes direction without head position changes, downward nystagmus in Dix-Hallpike maneuver, vertical skew deviation, and normal head impulse test (absence of corrective saccade) 1, 3
The American Academy of Otolaryngology-Head and Neck Surgery suggests that a positive Romberg test indicates central rather than peripheral vestibular pathology, and therefore Dix-Hallpike testing should not be performed as the initial maneuver 4

The American College of Radiology recommends ordering MRI brain without and with IV contrast for any patient with vertigo and positive Romberg test, as it can help detect acute brain lesions, posterior circulation infarcts, and other central causes 1, 2, 5
MRI detects acute brain lesions in 11% of patients with acute persistent vertigo and no focal neurologic deficits, and 75-80% of patients with posterior circulation infarcts causing acute vestibular syndrome have no obvious focal neurologic deficits 1, 2
CT head without contrast is inadequate for detecting CNS pathology in patients with isolated vertigo, and misses posterior fossa strokes in the acute phase 1, 2

The American College of Radiology recommends stabilizing the patient, obtaining urgent MRI brain without and with contrast, and activating stroke protocol if MRI shows posterior circulation stroke or cerebellar infarct 1, 2, 5
If MRI shows demyelinating disease (multiple sclerosis), neurology referral for disease-modifying therapy is recommended 5
If MRI shows mass lesion, neurosurgery consultation is recommended 5
If MRI is negative, consideration of spinal cord imaging (cervical/thoracic MRI) for posterior column pathology, vitamin B12 deficiency, copper deficiency, tabes dorsalis, and peripheral neuropathy evaluation is recommended 3

The American Academy of Otolaryngology-Head and Neck Surgery suggests not treating empirically as BPPV without first excluding central causes, and not performing canalith repositioning maneuvers until central pathology is excluded 3, 4
The American College of Radiology recommends not discharging without imaging when Romberg is positive with vertigo, and not relying on CT head as definitive imaging for this presentation 1, 2