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Central· Onset: Subacute (days to weeks) · Duration: Relapsing-remitting or progressive
Multiple sclerosis (vertigo manifestations)
Overview
Summary
MS plaques in the brainstem or cerebellum can produce a wide spectrum of vertigo and oculomotor abnormalities — INO is the classic localizing sign.
Diagnostic criteria
See the Bárány Society / clinical practice guideline papers[23,24] listed on the references page for the consensus diagnostic framework used in this profile.
Epidemiology
Vertigo is the presenting symptom of MS in ~5%; occurs at some point in ~30%.
Pathophysiology
Demyelinating plaques affecting the MLF (INO), root entry zone of the vestibular nerve, cerebellar peduncles, or floccular regions.
Prognosis
Variable; oculomotor signs often partially recover after acute attacks.
Key examination findings
- ◆INO (especially bilateral, in a young patient) is highly suggestive of MS.
- ◆Pendular nystagmus, gaze-evoked nystagmus, downbeat nystagmus all reported.
- ◆Optic neuritis history (Uhthoff's phenomenon, relative afferent pupillary defect, optic disc pallor).
- ◆Cerebellar signs (dysmetria, intention tremor).
Investigations
- ▸MRI brain & cervical cord with gadolinium — periventricular, juxtacortical, infratentorial T2 lesions.
- ▸Lumbar puncture: oligoclonal bands in CSF not in serum.
- ▸Evoked potentials (visual, somatosensory) for subclinical lesions.
Management
- ●Disease-modifying therapies (interferons, glatiramer, oral DMTs, monoclonal antibodies).
- ●Acute attacks: high-dose IV methylprednisolone.
- ●Symptomatic: 4-aminopyridine for downbeat nystagmus and gait.
Clinical pearls
- ★Bilateral INO in a person <40 = MS until proven otherwise.
- ★Unilateral INO in older patient → suspect brainstem stroke.