Reader response: Clinical Reasoning: Labyrinthine hemorrhage: An unusual etiology for peripheral vertigo

I read with interest the Resident & Fellow Clinical Reasoning by Drs. Parikh and Frank.¹ In differentiating peripheral (e.g., acute unilateral vestibular loss) from central causes of vertigo (e.g., acute posterior circulation stroke), the clinical head impulse test remains the most important clinical test. However, as a clinical test, it is subjective and, depending on examiner experience, its interpretation is variable. With the widespread availability of the video head impulse test, which provides quantitative information on the vestibulo-ocular reflex and catch-up saccade, the head impulse sign can be rapidly confirmed at point of care. This should now be considered part of the initial workup.