Abstract
Brainstem hemorrhage usually presented with acute multiple neurologic dysfunction, and the prognosis was poor. Rarely, it can manifest with audiovestibular symptoms only. Here, we report a case of brainstem hemorrhage involving the right middle cerebellar peduncle and dorsal lateral pons presented with constant nonpulsatile tinnitus and rotatory vertigo. We believed that rotatory nystagmus should be regarded as a central sign until proven otherwise even if the neurologic signs are subtle.
1
Introduction
Clinically, vertigo can be classified into peripheral and central type. Most of them can be distinguished from one another based on whether there are accompanied neurologic signs or not. However, it is not surprising that central vestibular disorder may be mistaken as a peripheral one if brainstem or cerebellar lesion manifests with audiovestibular symptoms only.
2
Case report
A 33-year-old man with a history of acute myelocytic leukemia, which had been in remission for more than 8 years, presented to our clinic because of sudden-onset 1-day spinning sensation after 5 days of sudden-onset right constant nonpulsatile tinnitus. On physical examination, he demonstrated bilateral, clockwise, nondirectional changing rotatory nystagmus in primary position and on gaze in all directions with symmetric and vivid pupil size. Neurologic examination was nonfocal and without signs of cranial nerve dysfunction, except those related to the vestibulocochlear nerve. A behavioral audiogram showed pure tone air and bone conduction thresholds within normal limits bilaterally. Auditory brainstem response testing in the right ear demonstrated absence of waves III and V. Caloric test showed 60% weakness on the right side. T1-weighted magnetic resonance imaging (MRI) of the head with gadolinium contrast revealed a hemorrhage measuring 1 × 1 cm in the right middle cerebellar peduncle (MCP) ( Fig. 1 A and B). In addition, T2-weighted MRI showed perifocal edema with involvement of right dorsolateral pons ( Fig. 1 C and D), which was compatible with subacute hemorrhage. He was transferred to neurosurgeon and treated with oral steroid with an uneventful recovery.
2
Case report
A 33-year-old man with a history of acute myelocytic leukemia, which had been in remission for more than 8 years, presented to our clinic because of sudden-onset 1-day spinning sensation after 5 days of sudden-onset right constant nonpulsatile tinnitus. On physical examination, he demonstrated bilateral, clockwise, nondirectional changing rotatory nystagmus in primary position and on gaze in all directions with symmetric and vivid pupil size. Neurologic examination was nonfocal and without signs of cranial nerve dysfunction, except those related to the vestibulocochlear nerve. A behavioral audiogram showed pure tone air and bone conduction thresholds within normal limits bilaterally. Auditory brainstem response testing in the right ear demonstrated absence of waves III and V. Caloric test showed 60% weakness on the right side. T1-weighted magnetic resonance imaging (MRI) of the head with gadolinium contrast revealed a hemorrhage measuring 1 × 1 cm in the right middle cerebellar peduncle (MCP) ( Fig. 1 A and B). In addition, T2-weighted MRI showed perifocal edema with involvement of right dorsolateral pons ( Fig. 1 C and D), which was compatible with subacute hemorrhage. He was transferred to neurosurgeon and treated with oral steroid with an uneventful recovery.
