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(Stroke. 2007;38:e26.)
© 2007 American Heart Association, Inc.

Letters to the Editor

Central Paroxysmal Positional Vertigo: Isolated Dizziness Caused by Small Cerebellar Hemorrhage

Department of Neurology and Stroke Center, Hiratsuka Kyosai Hospital, Hiratsuka, Japan

To the Editor:

Kerber et al¹ report that the proportion of cerebrovascular events in patients presenting to the emergency department with dizziness, vertigo, or imbalance is very low (3.2%), and when these symptoms are not accompanied by any other neurological signs or symptoms, stroke/transient ischemic attack is diagnosed in only 0.7% of patients. They conclude that dizziness, vertigo, and/or imbalance in isolation is a strong indicator of a noncerebrovascular cause. We agree with their conclusion. However, there is a potentially serious pitfall.

We reported the diagnoses in consecutive patients presenting to the emergency department of our hospital between April 2002 and March 2004 with isolated acute-onset dizziness symptoms (n=1332).² The proportion of these patients shown to have cerebrovascular disease was only 1.7% (22 of 1332). As in the Kerber et al¹ study, the percentage was very low. Among our patients, the most common diagnosis was benign paroxysmal positional vertigo (BPPV; 716 of 1332). BPPV has been recognized as the most common peripheral vestibular disorder,^2,3 and it is diagnosed simply on the basis of the characteristic positional nystagmus. Interest in BPPV is increasing because its underlying pathophysiology was clarified recently.^4–6

Small cerebellar hemorrhage, especially around the vermis, sometimes causes isolated dizziness symptoms with positional nystagmus similar to that of BPPV.^7,8 Although this "central paroxysmal positional vertigo" (CPPV) has long been recognized,^7,8 it has been underdiagnosed recently with the influx of information on BPPV. In our above-mentioned study,² CPPV caused by cerebellar hemorrhage (Figure), presenting with isolated dizziness symptoms and positional nystagmus, was ultimately diagnosed in 8 patients.² However, in 4 of these patients, CPPV was incorrectly diagnosed in the emergency room as BPPV; cerebellar hemorrhage was not correctly diagnosed until CT was performed a few days later. In our study patients, ischemia in the posterior inferior cerebellar artery territory was diagnosed more frequently (12) than CPPV(8). However, in cases of posterior inferior cerebellar artery territory ischemia, nystagmus is rather obscure in comparison to imbalance, and thus, differentiation from BPPV is not difficult.

View larger version (46K): [in this window] [in a new window]   A, CT scan of a patient with CPPV shows a small hemorrhage in the cerebellum. This lesion was typical of that seen in 7 other patients with CPPV. B, Video-oculographic recordings of horizontal eye movements obtained from the same patient. Ageotropic positional nystagmus appears with the head turned to the right in the supine position (top). The nystagmus changes direction as soon as the head is rolled toward the opposite side (bottom). Of our 8 CPPV patients, 6 presented with this horizontal direction-changing ageotropic positional nystagmus (mimicking horizontal canal cupulolithiasis), 1 presented with horizontal direction-changing geotropic positional nystagmus (mimicking horizontal canal canalolithiasis), and 1 presented with mixed torsional and vertical nystagmus during the Dix-Hallpike test (mimicking posterior canal canalolithiasis).

It is difficult to differentiate CPPV from BPPV, the more common peripheral vestibular disorder, on the basis of clinical presentation. We emphasize that we should re-recognize CPPV as a possible cause of acute-onset isolated dizziness symptoms and not hesitate to perform neuroradiologic examination even in patients previously diagnosed as having BPPV.

Acknowledgments

Disclosures

None.

References

1. Kerber KA, Brown DL, Lisabeth LD, Smith MA, Morgenstern LB. Stroke among patients with dizziness, vertigo, and imbalance in the emergency department: a population-based study. Stroke. 2006; 37: 2484–2487.[Abstract/Free Full Text]

2. Johkura K. Vertigo and dizziness associated with cerebrovascular diseases. Nihon Ishikai Zasshi. The Journal of the Japan Medical Association. 2005; 134: 1485–1490[in Japanese].

3. Bloom J, Katsarkas A. Paroxysmal vertigo in the elderly. J Otolaryngol. 1989; 18: 96–98.[Medline] [Order article via Infotrieve]

4. Hall SF, Ruby RR, McClure JA. The mechanics of benign paroxysmal vertigo. J Otolaryngol. 1979; 8: 151–158.[Medline] [Order article via Infotrieve]

5. Baloh RW, Jacobson K, Honrubia V. Horizontal semicircular canal variant of benign positional vertigo. Neurology. 1993; 43: 2542–2549.[Abstract/Free Full Text]

6. Baloh RW, Yue Q, Jacobson K, Honrubia V. Persistent direction-changing positional nystagmus: another variant of benign positional nystagmus? Neurology. 1995; 45: 1297–1301.[Abstract/Free Full Text]

7. Watson P, Barber HO, Deck J, Terbrugge K. Positional vertigo and nystagmus of central origin. Can J Neurol Sci. 1981; 8: 133–137.[Medline] [Order article via Infotrieve]

8. Brandt T. Positional and positioning vertigo and nystagmus. J Neurol Sci. 1990; 95: 3–28.[CrossRef][Medline] [Order article via Infotrieve]

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