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Tilt suppression refers to both tilting the head away from an Earth vertical axis and a reduction of an induced horizontal nystagmus. This phenomenon of reducing an induced horizontal nystagmus involves a circuitry of neurons within the vestibular nuclei and the cerebellum (collectively referred to as velocity storage) and signals from the otolith end organs. Lesions involving this circuitry can disrupt tilt suppression of induced horizontal nystagmus. We investigated the clinical value of combining the horizontal head-shaking nystagmus test with tilt suppression in 28 patients with unilateral peripheral vestibular hypofunction and 11 patients with lesions affecting the central nervous system. Each of the subjects with peripheral vestibular lesions generated an appropriately directed horizontal nystagmus after head shaking that then suppressed the induced angular slow phase velocity on average 52 ± 17.6% following tilt down of the head. In contrast, patients with central lesions had very little ability to suppress post-head-shaking nystagmus (mean 3.4 ± 56%). We recommend tilting the head after head shaking as a useful clinical test to assist in the differential diagnosis of vertiginous patients. In the case of unilateral peripheral vestibular hypofunction, head tilt suppresses the induced nystagmus via influence of the otolith organ. In the case of central pathology, the inability to suppress the nystagmus is from lesions impairing the otolith mediation on the velocity storage circuitry. [ABSTRACT FROM AUTHOR]

We sought to determine the cerebellar structures responsible for tilt suppression of post-rotatory nystagmus. We investigated ocular motor findings and MRI lesions in 73 patients with isolated cerebellar lesions who underwent recording of the vestibulo-ocular reflex (VOR) using rotatory chair tests. Tilt suppression of post-rotatory nystagmus was diminished in 27 patients (27/73, 37.0 %). The gains of the VOR and the TCs of per- and post-rotatory nystagmus did not differ between the patients with diminished and with normal tilt suppression. The patients with impaired tilt suppression showed perverted ('cross-coupled') head-shaking nystagmus (pHSN) and central positional nystagmus (CPN) more frequently than those with normal responses. Tilt suppression was impaired in five (71.4 %) of the seven patients with isolated nodulus and uvular infarction. Probabilistic lesion-mapping analysis showed that the nodulus and uvula are responsible for tilt suppression. Impaired tilt suppression may be ascribed to disruption of cerebellar contribution to the vestibular velocity-storage mechanism, which integrates information from the semicircular canals and otolith organs to help derive the brain's estimate of the head orientation relative to the pull of gravity. [ABSTRACT FROM AUTHOR]

The contention of this commentary, focused on the vestibulocerebellum (particularly the flocculus), is that the great importance for our understanding of cerebellar organization in terms of climbing fiber zones, begun years ago by Voogd [, ] and Oscarsson [], needs to be matched by coming more to grips with the other fundamental geometrical organization of the cerebellum, the parallel fibers. The central issue is the selection of those parallel fiber signals to be transformed into Purkinje cell activity in the different zones. At present, in comparison to our knowledge of vestibulocerebellar climbing fiber inputs, the deficiencies in our knowledge of the zonal anatomy and physiology of vestibulocerebellar mossy fibers and granule cells are glaring. The recent emphasis on molecularly oriented investigations points to the need to reinvigorate pursuit of unanswered questions about cerebellar anatomy, the handmaiden of physiology. [ABSTRACT FROM AUTHOR]

The nodulus and uvula (lobules X and IX of the vermis) receive mossy fibers from both vestibular afferents and vestibular nuclei neurons and are thought to play a role in spatial orientation. Their properties relate to a sensory ambiguity of the vestibular periphery: otolith afferents respond identically to translational (inertial) accelerations and changes in orientation relative to gravity. Based on theoretical and behavioral evidence, this sensory ambiguity is resolved using rotational cues from the semicircular canals. Recordings from the cerebellar cortex have identified a neural correlate of the brain's ability to resolve this ambiguity in the simple spike activities of nodulus/uvula Purkinje cells. This computation, which likely involves the cerebellar circuitry and its reciprocal connections with the vestibular nuclei, results from a remarkable convergence of spatially- and temporally-aligned otolith-driven and semicircular canal-driven signals. Such convergence requires a spatio-temporal transformation of head-centered canal-driven signals into an estimate of head reorientation relative to gravity. This signal must then be subtracted from the otolith-driven estimate of net acceleration to compute inertial motion. At present, Purkinje cells in the nodulus/uvula appear to encode the output of this computation. However, how the required spatio-temporal matching takes place within the cerebellar circuitry and what role complex spikes play in spatial orientation and disorientation remains unknown. In addition, the role of visual cues in driving and/or modifying simple and complex spike activity, a process potentially critical for long-term adaptation, constitutes another important direction for future studies. [ABSTRACT FROM AUTHOR]

Nodular infarctions are a rare cause of vertigo and may imitate vestibular neuritis. We report on two patients with acute positional vertigo due to nodular infarction, a clinical presentation is not reported so far. High-resolution MR imaging using thin slices is required to identify isolated nodular infarctions. [ABSTRACT FROM AUTHOR]

The vestibular nuclear complex (VNC) is classically divided into four nuclei on the basis of cytoarchitectonics. However, anatomical data on the distribution of afferents to the VNC and the distribution of cells of origin of different efferent pathways suggest a more complex internal organization. Immunoreactivity for calcium-binding proteins has proven useful in many areas of the brain for revealing structure not visible with cell, fiber or Golgi stains. We have looked at the VNC of the cat using immunoreactivity for the calcium-binding proteins calbindin, calretinin and parvalbumin. Immunoreactivity for calretinin revealed a small, intensely stained region of cell bodies and processes just beneath the fourth ventricle in the medial vestibular nucleus. A presumably homologous region has been described in rodents. The calretinin-immunoreactive cells in this region were also immunoreactive for choline acetyltransferase. Evidence from other studies suggests that the calretinin region contributes to pathways involved in eye movement modulation but not generation. There were focal dense regions of fibers immunoreactive to calbindin in the medial and inferior nuclei, with an especially dense region of label at the border of the medial nucleus and the nucleus prepositus hypoglossi. There is anatomical evidence that suggests that the likely source of these calbindin-immunoreactive fibers is the flocculus of the cerebellum. The distribution of calbindin-immunoreactive fibers in the lateral and superior nuclei was much more uniform. Immunoreactivity to parvalbumin was widespread in fibers distributed throughout the VNC. The results suggest that neurochemical techniques may help to reveal the internal complexity in VNC organization. [ABSTRACT FROM AUTHOR]

Protein kinase C isoforms PKC-δ and PKC-γ are expressed in Purkinje cells in the uvula-nodulus of the cerebellum. We examined the effect of Purkinje cell activity on the transcription, expression and intracellular distribution of PKC-δ and PKC-γ. Relative changes in activity were induced by unilateral labyrinthectomy (UL), decreasing the activity of Purkinje cells on the side of the labyrinthectomy relative to the contralateral side with intact vestibular input. After a UL, there was decreased immunolabeling of Purkinje cell axon terminals in the ipsilateral caudal vestibular complex by antisera to PKC-δ, but not PKC-γ. Western blots prepared from the uvula-nodulus and caudal vestibular complex showed an increase in the cytosolic PKC-δ and a decrease in membrane-associated PKC-δ in the ipsilateral uvula-nodulus 12–48 h after the UL. Hybridization histochemistry and semiquantitative reverse transcription polymerase chain reaction (RT-PCR) demonstrated no change in transcription of PKC-δ mRNA in the uvula-nodulus 1–240 h after unilateral labyrinthectomy. We conclude that both PKC-δ and PKC-γ are constitutively expressed in Purkinje cells. The targeting of PKC-δ, but not PKC-γ, to Purkinje neuron synaptic terminals is influenced by activity. [ABSTRACT FROM AUTHOR]

Properties of otolith inputs to vestibulocerebellar neurons were investigated in 14 adult cats. In the vestibular nuclei, we recorded single-unit activities that responded orthodromically after stimulation of the utricular and/or saccular nerves and antidromically after stimulation of the cerebellum (uvula-nodulus and anterior vermis). Descending axonal projections to the spinal cord were also examined by antidromic stimulation of the caudal end of the C1 segment. Forty-seven otolith-activated neurons that projected to the uvula-nodulus were recorded. Thirteen (28%) of the 47 neurons received convergent inputs from the utriculus and sacculus. The remaining 34 (72%) vestibular neurons were non-convergent neurons: 18 (38%) received utricular input alone, and 16 (34%) received saccular input alone. Most (35/47) vestibulocerebellar neurons were located in the descending vestibular nucleus and only one of these projected to the spinal cord. Seven of the 47 vestibulocerebellar neurons were located in the lateral vestibular nucleus and most of these neurons projected to the spinal cord. The remaining neurons were located in group X (two neurons) and the superior vestibular nucleus (three neurons). In a different series of experiments, 37 otolith-activated vestibular neurons were tested to determine whether they projected to the uvula-nodulus and/or the anterior vermis. Nineteen of the 37 neurons projected to the anterior vermis, 13/37 projected to the uvula-nodulus, and 5/37 projected to both. The utricular and/or saccular nerve-activated vestibulocerebellar neurons projected to not only the uvula-nodulus, but also to the anterior vermis. In summary, the results of this study showed that vestibular neurons receiving inputs from the utriculus and/or sacculus projected to the cerebellar cortex. This indirect otolith-cerebellar pathway terminated both in the anterior lobe and in the uvula/nodulus. [ABSTRACT FROM AUTHOR]

Connections of Purkinje cell axons of lobule X (nodulus) with vestibulocerebellar neurons projecting to lobule X or IX (uvula) were revealed in the rat. Purkinje cell axons were anterogradely labeled with biotinylated dextran (BD) injected into sublobule Xa while vestibular neurons were retrogradely labeled with cholera toxin subunit B (CTB) injected into sublobule Xa or IXc. Labeled terminals of Purkinje cell axons of lobule X were numerous in the superior vestibular nucleus (SV), medial parts of the parvocellular (MVpc) and the caudal part (MVc) of the medial vestibular nucleus (MV), and group y. These subdivisions of the vestibular nuclei contained many neurons projecting to lobule X or IX. Lobule-X-projecting and lobule-IX-projecting neurons were in contact with terminals of Purkinje cell axons of lobule X in the MVpc and MVc. They were distributed dorsally to medially in medial parts of the MVpc and MVc. The present study suggests that Purkinje cells in lobule X regulate the output of a population of lobule-X-projecting or lobule-IX-projecting neurons of the MVpc and MVc. [ABSTRACT FROM AUTHOR]

Connections of Purkinje cell axons of lobule X (nodulus vermis) with vestibulospinal neurons have been demonstrated in the rat, by anterograde labeling of axons with biotinylated dextran (BD) injected into sublobule Xa and by retrograde labeling of neurons with cholera toxin subunit B (CTB) injected into cervical segments. Labeled terminals of Purkinje cell axons were numerous in the superior vestibular nucleus, the parvocellular (MVpc) and the caudal part (MVc) of the medial vestibular nucleus (MV), and group y. A limited number of labeled terminals were seen in the caudal part of the descending vestibular nucleus (DV). Occasional labeled terminals were seen in the lateral part of the lateral vestibular nucleus (LV) whereas few labeled terminals were seen in the magnocellular part of the MV (MVmc). Vestibulospinal neurons labeled from the C2 and C3 segments were seen bilaterally in the MVmc, MVpc, MVc, and DV, and ipsilaterally in the LV. CTB-labeled vestibulospinal neurons in contact with BD-labeled terminals of Purkinje cell axons were identified in the lateral part of the MVpc, near the border between the MVpc and MVmc, or close to the dorsal acoustic stria, and in the middle part of the MVc at its rostral level. The present study suggests that Purkinje cells of lobule X regulate the output of cervical-projecting vestibulospinal neurons in the MVpc and MVc. [ABSTRACT FROM AUTHOR]

The nodulus and sublobule d of the uvula of rhesus and cynomolgus monkeys were electrically stimulated with short trains of pulses to study changes in horizontal slow-phase eye velocity. Nodulus and uvula stimulation produced a rapid decline in horizontal slow phase velocity, one aspect of the spatial reorientation of the axis of eye rotation that occurs when the head is tilted with regard to gravity during per- and post-rotatory nystagmus and optokinetic after-nystagmus (OKAN). Nodulus and uvula stimulation also reproduced the reduction of the horizontal time constant of post-rotatory nystagmus and OKAN that occurs during visual suppression. The brief electric stimuli (4-5 s) induced little slow-phase velocity and had no effect on the initial jump in eye velocity at the onset or the end of angular rotation. Effects of stimulation were unilateral, suggesting specificity of the output pathways. Activation of more caudal sites in the uvula produced nystagmus with a rapid rise in eye velocity, but the effects did not outlast the stimulus and did not affect VOR or OKAN time constants. Thus, stimulation of caudal parts of the uvula did not affect eye velocity produced by velocity storage. We postulate that the nodulus and sublobule d of the uvula control the time constant of the yaw axis (horizontal) component of slow-phase eye velocity produced by velocity storage. [ABSTRACT FROM AUTHOR]

We habituated the dominant time constant of the horizontal vestibuloocular reflex (VOR) of rhesus and cynomolgus monkeys by repeated testing with steps of velocity about a vertical axis and adapted the gain of the VOR by altering visual input with magnifying and reducing lenses. After baseline values were established, the nodulus and ventral uvula of the vestibulocerebellum were ablated in two monkeys, and the effects of nodulouvulectomy and flocculectomy on VOR gain adaptation and habituation were compared. The VOR time constant decreased with repeated testing, rapidly at first and more slowly thereafter. The gain of the VOR was unaffected. Massed trials were more effective than distributed trials in producing habituation. Regardless of the schedule of testing, the VOR time constant never fell below the time constant of the semicircular canals (≈5 s). This finding indicates that only the slow component of the vestibular response, the component produced by velocity storage, was habituated. In agreement with this, the time constant of optokinetic after-nystagmus (OKAN) was habituated concurrently with the VOR. Average values for VOR habituation were obtained on a per session basis for six animals. The VOR gain was adapted by natural head movements in partially habituated monkeys while they wore ×2.2 magnifying or ×0.5 reducing lenses. Adaptation occurred rapidly and reached about ±30%, similar to values obtained using forced rotation. VOR gain adaptation did not cause additional habituation of the time constant. When the VOR gain was reduced in animals with a long VOR time constant, there were overshoots in eye velocity that peaked at about 6-8 s after the onset or end of constant-velocity rotation. These overshoots occurred at times when the velocity storage integrator would have been maximally activated by semicircular canal input. Since the activity generated in the canals is not altered by visual adaptation, this finding indicates that the gain element that controls rapid changes in eye velocity in the VOR is separate from that which couples afferent input to velocity storage. Nodulouvulectomy caused a prompt and permanent loss of habituation, returning VOR time constants to initial values. VOR gain adaptation, which is lost after flocculectomy, was unaffected by nodulouvulectomy. Flocculectomy did not alter habituation of the VOR or of OKAN. Using a simplified model of the VOR, the decrease in the duration of vestibular nystagmus due to habituation was related to a decrement in the dominant time constant of the velocity storage integrator (1/ h). Nodulouvulectomy, which reversed habituation, would be effected by decreasing h, thereby increasing the VOR time constant. Small values of h would cause velocity storage to approach an ideal integrative process, leading the system to become unstable. By controlling the VOR time constant through habituation, the nodulus and uvula can stabilize the slow component of the VOR. VOR gain adaptation was related to a modification of the direct vestibular path gain g, without altering the coupling to velocity storage g or its time constant (1/ h). The mismatched direct- and indirect-pathway gains simulated the overshoots in the dynamic response to a step in velocity, that were observed experimentally. We conclude that independent distributed elements in the VOR modify its dynamic response, under control of separate parts of the vestibulocerebellum. [ABSTRACT FROM AUTHOR]

Under anesthesia with NO (70%) and halothane (2-4%), Purkinje cell activities were extracellularly recorded in the flocculus and nodulus of immobilized pigmented rabbits. Large field (60° × 60°) optokinetic stimulation (OKS) was delivered to the central visual field of one eye with a constant velocity (0.1-4.0 °/S) at 0°, 45°, 90° or 135° to the horizontal plane of the eye. Most of the Purkinje cells in the flocculus and the nodulus showed significant simple spike modulations to OKS delivered to either eye. As a whole, the preferred directions of simple spike responses in the flocculus had the same orientation as those of complex spike responses. However, the preferred directions and amplitudes of modulation of simple spike responses did not necessarily correlate with those of complex spike responses in individual flocculus Purkinje cells. On the other hand, the preferred directions of simple and complex spike responses were not necessarily in the same orientation in the nodulus. The optimum velocity for simple spike responses was in the range 0.1-2.0°/s for Purkinje cells in both the flocculus and the nodulus. The amplitude and time to peak of the simple spike responses of nodulus Purkinje cells were significantly smaller and longer, respectively, than those of flocculus Purkinje cells. In both the flocculus and the nodulus, Purkinje cells whose simple spikes preferred the horizontal orientation (H cells) and the vertical orientation (V cells) showed clustering. In particular, zonal organization was noted in the flocculus. H cells were localized in a dorso-ventral zone in the rostral one third of the flocculus, and V cells were in two distinct zones rostral and caudal to the H cell zone. The locations of H and V cells in the flocculus correspond to the H zone and V zones, respectively, determined on the basis of the preferred directions of complex spike responses to OKS. This indicates that the same subdivisions of the flocculus are supplied with optokinetic signals with the same orientation selectivity through both mossy and climbing fibers, and suggest that such subdivisions of the flocculus are functional units which control horizontal and vertical components of optokinetic eye movements. The present results indicate that the flocculus and the nodulus are supplied with distinct optokinetic signals through mossy fibers and play different roles in controlling optokinetic eye movements. [ABSTRACT FROM AUTHOR]

Under anesthesia with NO (70%) and halothane (2-4%), complex spikes of Purkinje cells were extracellularly recorded in the nodulus and flocculus of immobilized pigmented rabbits. Optokinetic stimulation (OKS) was delivered to each eye as repetitive movements of a random dot pattern. The visual field of each eye was divided into anterior, central and posterior fields at axes 45° and 135° along the horizon. With OKS of the ipsilateral eye, the preferred direction of complex spike responses was: (1) forward (F) in all visual fields (F response), (2) upward (U) in both the anterior and central visual fields but downward (D) in the posterior visual field (U response), or (3) no response (N) in any of the visual fields (N response). With OKS of the contralateral eye, the preferred direction was: (1) backward (B) in both the anterior and central visual fields but N in the posterior visual field (B response), (2) U in the anterior but D in both the central and posterior visual fields (D response), or (3) N in all visual fields. Purkinje cells were classified into five categories in terms of the complex spike responses to OKS to the central visual fields of the ipsi-/contralateral eyes: F/B, F/N, U/D, U/N and N/D types. In cells with ipsi-F and/or contra-B responses, OKS delivered above the horizon induced F and/or B responses, but OKS below the horizon induced no response. In cells with contra-D response, OKS both above and below the horizon induced D responses. Cells with ipsi-U responses showed unusually complex direction selectivity: in the anterior, central and posterior fields, the preferred direction was U, U and D, respectively, above the horizon, as opposed to N, D and D below the horizon. In the nodulus, F/B and F/N type cells were localized in the ventral lamella within two distinct longitudinal zones about 0.5-1.5 and 2.5-3.5 mm from the midline, while U/D, U/N and N/D type cells were found in both the ventral and dorsal lamellae within a longitudinal zone about 1.5-2.5 mm from the midline. In the flocculus, the locations of F/N (or F/B), U/N and N/D type cells roughly corresponded to H, anterior V and R zones, respectively, as previously reported on the basis of the direction of eye movements induced by microstimulation. The receptive field of visual climbing fiber inputs to the nodulus and flocculus is organized such that complex spike activity is best modulated with retinal image slips caused by head rotation around the axis of either the horizontal (F/B, F/N types) or the anterior canal (U/D, U/N, N/D types) on the ipsilateral side. [ABSTRACT FROM AUTHOR]

In pigmented rabbits anesthetized with NO (70%) and halothane (2-4%), Purkinje cells were extracellularly recorded in the nodulus. Large field (60°×60°) optokinetic stimulation (OKS) with constant velocity was delivered to either the ipsi- or contralateral eye, and the direction and velocity selectivities of complex spike responses were examined. To ipsilateral OKS ( n = 181), the preferred direction was forward (F, n = 72), upward (U, n = 38) or downward (D, n = 10), while the remaining cells ( n = 61) showed no response (N). To contralateral OKS ( n = 117), the preferred direction was backward (B, n = 22), upward (U, n = 7) or downward (D, n = 22), while the rest ( n = 66) showed N. Cells tested with both eyes ( n = 95) fell into 8 categories based on the preferred direction to ipsi- and contralateral OKS: (1) ipsi-F and contra-B (F/B type, n = 20), (2) ipsi-F but contra-N (F/N type, n = 12), (3) ipsi-U and contra-D (U/D type, n = 15), (4) ipsi-U but contra-N (U/N type, n = 13), (5) ipsi-N but contra-D (N/D type, n = 1), (6) ipsi-D but contra-N (D/N type, n = 5), (7) ipsi-N but contra-U (N/U type, n = 6), and (8) N to both eyes (N/N type, n = 23). The optimum velocity was in the range 0.1-2.0°/s for all cells responsive to OKS. In the ventral lamella, four medio-laterally aligned zones were demonstrated. In the most medial zone (0-0.5 mm from the midline), the majority of cells showed ipsi-N or contra-N responses. In the second zone (0.5-1.5 mm), most cells preferred ipsi-F or contra-B directions. In the third zone (1.5-2.5 mm), most cells preferred ipsi-U or contra-D directions. In the most lateral zone (2.5-3.5 mm), most cells preferred ipsi-F or contra-B directions. In the dorsal lamella, a longitudinal zone characterized with cells preferring ipsi-U or contra-D directions was found about 1.5-2.5 mm from the midline. This zone seemed to be the continuation of the third zone in the ventral lamella. Cells preferring ipsi-D or contra-U directions were scattered in the medial half of both the dorsal and ventral lamellae. Most cells responsive to electrical stimulation of the contralateral optic tract (OT) preferred the ipsi-F direction and were localized in the second and the most lateral zones of the ventral lamella. As for cells activated by a climbing fiber with a branching axon to the flocculus, no characteristic feature was found in terms of the preferred direction to OKS, except that none of the cells preferring ipsi-D or contra-U directions were activated by such branching climbing fibers. The results indicate that the nodulus consists of at least four functionally distinct zones in terms of direction selectivity of visual climbing fiber afferents. [ABSTRACT FROM AUTHOR]

The distribution of vestibular neurons projecting to the flocculus and the nodulus and uvula of the caudal vermis (Larsell's lobules X and IX) was investigated with retrograde axonal transport of horseradish peroxidase and the fluorescent tracers Fast Blue, Nuclear Yellow and Diamidino Yellow. The presence of collateral axons innervating the flocculus on one hand and the nodulus and uvula on the other was studied with simultaneous injection of the different fluorescent tracers. The distribution of vestibular neurons projecting to either flocculus or caudal vermis is rather similar and has a bilateral symmetry. The projection from the magnocellular medial vestibular nucleus is very sparse, while that from the lateral vestibular nucleus is absent. The majority of labeled neurons was found in the medial, superior, and descending vestibular nuclei, in that order. Double labeled neurons were distributed in a similar way as the single labeled ones. Labeled neurons project to the nodulus and uvula, the flocculus, and to both parts of the cerebellum simultaneously in a ratio of 12:4:1. Five different populations of vestibulocerebellar neurons can be distinguished on the basis of their projection to the: (1) ipsilateral flocculus, (2) contralateral flocculus, (3) ipsilateral flocculus and nodulus/uvula, (4) contralateral flocculus and nodulus/uvula, and (5) nodulus/uvula. [ABSTRACT FROM AUTHOR]

The occurrence and distribution of labeled cells in the pontine nuclei were mapped following injections of small amounts of horseradish peroxidase (0.05-0.5 μl, 50% suspension) in the flocculus, nodulus and the dorsal and ventral paraflocculus in adult albino rabbits. While no labeled cells were found in the pontine nuclei following injections in the nodulus, some were present following injections in the flocculus and a great number following injections in the paraflocculus. The projections onto the flocculus and paraflocculus are precisely organized. Following injections in the paraflocculus labeled neurons are arranged in four columns (E and G in the paramedian pontine nucleus, F in the peduncular and H in the dorsolateral nucleus). Following injections in the ventral paraflocculus labeled cells are present only in parts of column E and F, while columns G and H and parts of E and F project onto the dorsal paraflocculus. Following injections in the flocculus labeled cells occur in the rostral part of column E only. A comparison between the sites of termination of pontine afferents and the areas giving origin to floccular and parafloccular fibers shows that only few fibers mediating visual impulses end in these pontine areas, while they receive numerous fibers from gyrus cinguli and areas 18 and 19 of the cerebral cortex. [ABSTRACT FROM AUTHOR]

Positional vertigo and nystagmus without associated neurological symptoms and signs are characteristic features of benign paroxysmal positional vertigo (BPPV). Although positional nystagmus may occur with caudal cerebellar infarction including the nodulus, positional nystagmus is usually associated with other neurological signs such as spontaneous or gaze-evoked nystagmus, perverted head-shaking nystagmus, cerebellar dysmetria, or severe gait ataxia with falling. We present a patient with nodular infarction who had positional vertigo with nystagmus as a sole manifestation. Video-oculography showed apogeotropic positional horizontal nystagmus during head turning while supine, which was consistent with apogeotropic BPPV involving the horizontal canal. MRI disclosed acute infarct in the nodulus. Nodulus infarction should be considered in a patient with positional nystagmus, especially when the presenting symptoms and signs are consistent with BPPV involving the horizontal canal. [ABSTRACT FROM AUTHOR]