Palliative systemic therapy in a rare case of positional vertigo

A 73-year-old female patient presented to our clinic with vertigo. The vertigo had been slowly progressive for five weeks and was aggravated by movement and by rolling to the right side in bed. Two weeks before, an inpatient evaluation had already been performed alio loco. A cranial computed tomography (cCT) had shown no evidence of ischemia or hemorrhage. The patient was treated for of benign paroxysmal positional vertigo (BPPV). On the day of clinical examination, there was no spontaneous nystagmus or deviation of skew, and the video head pulse test was regular. There was gait unsteadiness with an undirected tendency to fall. The Dix-Hallpike maneuver and the supine roll test to the left each showed rotatory nystagmus to the left. Repeated emesis occurred during the Epley release maneuver resulting in termination. Due to atypical findings, cranial magnetic resonance imaging (cMRI) was performed, which revealed multiple cerebral metastases, the largest in the cerebellar vermis. Ultimately, after further diagnostics, metastatic medullary thyroid carcinoma was diagnosed, and palliative systemic therapy was initiated. In most cases the treatment of BPPV of the posterior or horizontal canal is possible by performing the correct release maneuver two times. In refractory cases in addition to simultaneous BPPV of other canals or conversion, e.g., from posterior to horizontal canal, a central cause must be considered. This may be ischemic, inflammatory, or neoplastic lesions of the pons, medulla oblongata, or cerebellum. The diagnostic of choice is then a cMRI. The presented case is supposed to illustrate the necessity of interdisciplinary diagnostics and therapy in order not to overlook rarer and dangerous causes, especially in cases refractory to therapy.