Resident corner: Episodic imbalance

Abstract

Resident corner 77 Case vignetteA 70-year-old woman with hypertensive cardiomyopathy was referred to the neurologist because of increasing episodic imbalance during standing and walking. In fact, for two weeks she could only ambulate with a walker. Two days ago, she misstepped and fell on her left shoulder, which has hurt since then. A bone fracture was excluded. Otherwise the patient's past medical history was unremarkable. The initial clinical investigation by the neurologist aimed to exclude a neuro-otological disorder. Visual fixations were conjugate in all directions. There was no spontaneous or gaze-evoked nystagmus during normal viewing and with Frenzel glasses. Saccadic, smooth pursuit, and vergence eye movements were normal. There were no pupillary a bnormalities. The horizontal head impulse test revealed no catch-up saccades on either side. There was no nystagmus during vibration of the mastoids or after head shaking with Frenzel glasses. Five seconds after positioning the patient in the right head-hanging Dix-Hallpike (Dix and Hallpike 1952) position, a strong geotropic vertical-torsional nystagmus developed and lasted about 30 seconds, during which the patient complained of strong rotatory vertigo.