Monthly Archives: October 2014

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.