Journal of Neurology

, Volume 261, Issue 1, pp 121–129

Isolated vestibular nuclear infarction: report of two cases and review of the literature

  • Hyo-Jung Kim
  • Seung-Han Lee
  • Jae Han Park
  • Jung-Yoon Choi
  • Ji-Soo Kim
Original Communication

DOI: 10.1007/s00415-013-7139-0

Cite this article as:
Kim, HJ., Lee, SH., Park, J.H. et al. J Neurol (2014) 261: 121. doi:10.1007/s00415-013-7139-0

Abstract

Cerebral infarction presenting with isolated vertigo remains a diagnostic challenge. To define the clinical characteristics of unilateral infarctions restricted to the vestibular nuclei, two patients with isolated unilateral vestibular nuclear infarction had bedside and laboratory evaluation of the ocular motor and vestibular function, including video-oculography, bithermal caloric irrigation, the head impulse test (HIT) using magnetic scleral coils, and cervical and ocular vestibular-evoked myogenic potentials (VEMPs). We also reviewed the literature on isolated vertigo from lesions restricted to the vestibular nuclei, and analyzed the clinical features of seven additional patients. Both patients showed spontaneous torsional-horizontal nystagmus that beat away from the lesion side, and direction-changing gaze-evoked nystagmus. Recording of HIT using a magnetic search coil system documented decreased gains of the vestibular-ocular reflex for the horizontal and posterior semicircular canals on both sides, but more for the ipsilesional canals. Bithermal caloric tests showed ipsilesional canal paresis in both patients. Cervical and ocular VEMPs showed decreased or absent responses during stimulation of the ipsilesional ear. Initial MRIs including diffusion-weighted images were normal or equivocal, but follow-up imaging disclosed a circumscribed acute infarction in the area of the vestibular nuclei. Infarctions restricted to the vestibular nuclei may present with isolated vertigo with features of both peripheral and central vestibulopathies. Central signs should be sought even in patients with spontaneous horizontal–torsional nystagmus and positive HIT. In patients with combined peripheral and central vestibulopathy, a vestibular nuclear lesion should be considered especially when hearing is preserved.

Keywords

Vestibulopathy Vestibular nucleus Lateral medullary infarction Vertigo 

Supplementary material

415_2013_7139_MOESM1_ESM.wmv (17.7 mb)
Supplementary material 1 Video 1: Spontaneous and gaze-evoked nystagmus in patient 1. Spontaneous left-beating horizontal-torsional nystagmus increases with removal of visual fixation and during left eccentric gaze, and changes into right beating during rightward gaze. (WMV 18130 kb)
415_2013_7139_MOESM2_ESM.wmv (9.7 mb)
Supplementary material 2 Video 2: Bedside head impulse tests in patient 1. The patient shows a corrective catch-up saccade during head impulse to the right. (WMV 9943 kb)
415_2013_7139_MOESM3_ESM.wmv (14 mb)
Supplementary material 3 Video 3: Spontaneous and gaze-evoked nystagmus in patient 2. Spontaneous left beating horizontal-torsional nystagmus increases without fixation and during left eccentric gaze, and changes into right beating during rightward gaze. (WMV 14333 kb)
415_2013_7139_MOESM4_ESM.wmv (14.7 mb)
Supplementary material 4 Video 4: Bedside head impulse tests in patient 2. The patient shows a corrective catch-up saccade during head impulses for the horizontal and posterior canals on both sides, more marked for the ipsilesional ones.(WMV 15013 kb)

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • Hyo-Jung Kim
    • 1
    • 2
  • Seung-Han Lee
    • 3
  • Jae Han Park
    • 2
  • Jung-Yoon Choi
    • 4
  • Ji-Soo Kim
    • 2
  1. 1.Biomedical Research InstituteSeoul National University Bundang HospitalSeongnamKorea
  2. 2.Department of NeurologySeoul National University College Medicine, Seoul National University Bundang HospitalSeongnamKorea
  3. 3.Department of NeurologyChonnam National University Medical SchoolGwangjuKorea
  4. 4.Department of NeurologyKorea University College of Medicine, Korea University Ansan HospitalAnsanKorea

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