Disequilibrium double-whammy: A case of concurrent BPPV and cerebellar stroke

Abstract

Introduction: Benign paroxysmal positional vertigo (BPPV) and cerebellar stroke can both present with vertigo. They are not commonly described to occur simultaneously, although BPPV remains an independent risk factor for ischaemic strokes. This paper reports a patient presenting with classical BPPV shown to have cerebellar infarction.

Case Report: A 50 year old man, presenting with vertigo was diagnosed with BPPV, following clinical examination, Semont manoeuvre, Dix-Hallpike’s manoeuvre and Brandt Daroff exercise/ procedure. Magnetic Resonance Imaging demonstrated acute cerebellar infarctions, on a background of multiple vascular risk factors, suggesting these presented as BPPV.

Discussion: BPPV, non-sustained vertigo triggered by changes in head position, is produced by irritation of the cupula of semicircular canals by calcium carbonate deposits. Both BPPV and posterior circulation infarctions cause vertigo, with BPPV being an independent risk for ischaemic strokes. BPPV led to the presentation but investigation confirmed concurrent diagnosis of acute cerebellar infarctions. He responded to Brandt Daroff exercises and was asymptomatic at discharge. Assuming the BPPV was the presentation of the stroke, suggesting a central cause thereof, the underlying pathophysiology of the BPPV remains obscure. The alternative explanation is that the case represents a propicious, coincidental occurrence of both diagnoses. He subsequently suffered further ischaemic stroke, due to an underlying clopidogrel resistance, and suffered significant morbidity as a result. Patients presenting with clinical diagnosis of BPPV rarely undergo screening for stroke, especially affecting the posterior circulation, potentially explaining the paucity of data regarding concurrent BPPV and cerebellar strokes.

Conclusions: Posterior-circulation stroke should be considered in patients presenting with BPPV symptoms.