Woman 53yr with symptoms which resembles BPPV history, but not very convincing. Her vertigo started in the morning while she was still in the bed with feeling of sinking. All the time she is dizzy and she can’t move the head neither eyes because it worsens her dizziness; slight instability. She vomited for two times. The same symptoms she had two months ago after yoga exercises and three days after, canalith repositioning maneuver completely resolved her symptoms.
No spont Ny. VHIT is good. But Dix-Hallpike shows downbeating nystagmus which is accompanied with slight vertigo (slightly stronger at the right side).
OK. Let’s check for the central vestibular function.
VNG shows good saccades but smooth pursuit is rather saccadic at both directions more pronounced to the right. But the patient is very drowsy because of Chloropyramine (antihystamine).
I’ve performed Epley (for the right) and demi-Semone.
On the next day she is still dizzy and Dix-Hallpike still shows downbeat nystagmus. Also there’s slight myosis at the right eye.
VNG shows better tracking gains but gain to the right is significantly lower!
Deep-head hanging maneuver and Epley didn’t resolved the downbeat nystagmus (slightly less intense).
Few days later, she is without vertigo and also without any positional nystagmus.
Would you attribute her positional downbeat nystagmus:
– to BPPV (anterior or apogeotropic posterior) or
– to arachnoid cyst in contact with 8th cranial nerve and right cerebellar lobe?
Do you send every positional down-beat nystagmus to MRI?
What’s the significance of asymmetric smooth pursuit gain?
According to Timothy C. Hain asymmetric smooth pursuit gain is because of:
– Acute parietal lobe disorder
– Acute frontal lobe disorder
– Superimposed nystagmus
– Lesion of pontine nuclei