Category Archives: Anterior Canal BPPV

Positional Down Beat Nystagmus: Central or Peripheral

Patient 52yr waked up with positional vertigo: when he turned in bed, he felt strong short vertigo. On the next day he leaned forward (fixing washing machine) and then he felt strong vertigo, instability, nausea and vomiting. After that restrictive movements and sleeping on big pillows.

Very standard history for BPPV, isn’t it?

Dix-Hallpike test: Down Beating Nystagmus with very discreate cw torsion component but without vertigo! He felt vertigo when returning to the sitting position.

Deep head hanging maneuver didn’t work. Than Epley from the right side. After that control DH test ok.

Five days later he was still dizzy but positional testing: from standing with head bent to the left, when he quickly raise head to the upright position, he felt short spin and I saw two downbeating Ny.
Calorics, VHIT, SVV, oVEMP and oto-neurological exam normal.

I send him to perform MRI as I do evry time when I see down-beating Ny

MRI demonstrated two lesions at cerebellar peduncles bilaterally
MRI cerebellar peduncle lesion

On that occasion (15 days later) Dix-Hallpike was possitive to the right. Usual upbeating and torsional ccw Ny.

After one Epley meneuver he is without any vestibular complaints.

Positional downbeating Ny in patient with instability as dominant symptom

Three weeks ago 75year old woman wakes up with slight instability and nausea. Hour later when she tried to lay down something strongly pushes her to bad, strong vertigo with nausea starts. The vertigo didn’t last long (very restrictive movements) but she had very pronounced instability and strong nausea for the whole day. Since that day she is very unstable but walks by herself. She mentioned that she had also one episode of worsening of her instability when she tried to get up.
This patient has artificial valve and takes anticoagulant therapy; she has hypertension, hyperlipidemia and diabetes and tremor of arms.

Neurootological exam: smooth pursuit, saccadic movements, OKN functions ok. Cerebellar exam ok (tremor of hands)
Bitherlmal caloric test: 17% paresis of left side

VHIT: VOR gain is bilaterally reduced 0.74 with predominantly covert saccades
reduction in VOR gain can be explained by her age

Dix-Hallpike: very strong downbeating nystagmus, stronger on the right side !

Deep head hanging maneuver was performed twice with no improvement at all.
Epley maneuver for the right ear was performed, and after each maneuver, Ny was lessen. Finaly after third Epley Ny disappeared; control DH test at both side was negative. Patient felt better but left my office still unstable.
From day after she has no vestibular problems, almost everything returned to normal. She walks much stable but not as before (she’s afraid).
Brain MRI shows two lacunar ischemic lesions subcorticaly.