Paradigm shift in acute dizziness: is caloric testing obsolete?

Morrison, Miranda; Korda, Athanasia; Zamaro, Ewa; Wagner, Franca; Caversaccio, Marco D.; Sauter, Thomas C.; Kalla, Roger; Mantokoudis, Georgios (2022). Paradigm shift in acute dizziness: is caloric testing obsolete? Journal of neurology, 269(2), pp. 853-860. Springer 10.1007/s00415-021-10667-7

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Cold and warm water ear irrigation, also known as bithermal caloric testing, has been considered for over 100 years the 'Gold Standard' for the detection of peripheral vestibular hypofunction. Its discovery was awarded a Nobel Prize. We aimed to investigate the diagnostic accuracy of Caloric Testing when compared to the video head impulse test (vHIT) in differentiating between vestibular neuritis and vestibular strokes in acute dizziness.


Prospective cross-sectional study (convenience sample).


All patients presenting with signs of an acute vestibular syndrome at the emergency department of a tertiary referral center.


One thousand, six hundred seventy-seven patients were screened between February 2015 and May 2020 for Acute Vestibular Syndrome (AVS), of which 152 met the inclusion criteria and were enrolled. Inclusion criteria consisted of a state of continuous dizziness, associated with nausea or vomiting, head-motion intolerance, new gait or balance disturbance and nystagmus. Patients were excluded if they were younger than 18 years, if symptoms lasted < 24 h or if the index ED visit was > 72 h after symptom onset. Of the 152 included patients 85 completed testing. We assessed 58 vestibular neuritis and 27 stroke patients.


All patients underwent calorics and vHIT followed by a delayed MRI which served as a gold standard for vestibular stroke confirmation.


The overall sensitivity and specificity for detecting stroke with a caloric asymmetry cut-off of 30.9% was 75% and 86.8%, respectively [negative likelihood ratio (NLR) 0.29] compared to 91.7% and 88.7% for vHIT (NLR 0.094). Best VOR gain cut-off was 0.685. Twenty-five percent of vestibular strokes were misclassified by calorics, 8% by vHIT.


Caloric testing proved to be less accurate than vHIT in discriminating stroke from vestibular neuritis in acute dizziness. Contrary to classic teaching, asymmetric caloric responses can also occur with vestibular strokes and might put the patient at risk for misdiagnosis. We, therefore, recommend to abandon caloric testing in current practice and to replace it with vHIT in the acute setting. Caloric testing has still its place as a diagnostic tool in an outpatient setting.

Item Type:

Journal Article (Original Article)


04 Faculty of Medicine > Department of Intensive Care, Emergency Medicine and Anaesthesiology (DINA) > University Emergency Center
04 Faculty of Medicine > Department of Head Organs and Neurology (DKNS) > Clinic of Neurology
04 Faculty of Medicine > Department of Head Organs and Neurology (DKNS) > Clinic of Ear, Nose and Throat Disorders (ENT)
04 Faculty of Medicine > Department of Radiology, Neuroradiology and Nuclear Medicine (DRNN) > Institute of Diagnostic and Interventional Neuroradiology

UniBE Contributor:

Morrison, Miranda Claire, Korda, Athanasia, Zamaro, Ewa, Wagner, Franca, Caversaccio, Marco, Sauter, Thomas Christian, Kalla, Roger, Mantokoudis, Georgios


600 Technology > 610 Medicine & health








Martin Zbinden

Date Deposited:

04 Oct 2021 15:37

Last Modified:

05 Dec 2022 15:53

Publisher DOI:


PubMed ID:


Uncontrolled Keywords:

Acute stroke Caloric testing Dizziness Head-impulse test Neuritis Vertigo




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