There was mild mass effect and surrounding edema, but no significant midline shift. This demonstrated a 4.3 × 2.5 cm acute intraparenchymal hemorrhage in the right occipital lobe, and a small amount of subarachnoid hemorrhage in the right basal cistern and cerebellopontine angle. The symptoms of vertigo, severe nausea, and blurred vision persisted after 30 min and the patient was transferred to the emergency department for emergent assessment, including CT angiogram of the brain.Ĭontrast-enhanced CT angiography of the brain was performed (Fig. Vital signs obtained in clinic were a blood pressure of 178/58, and pulse of 66.

She then complained of blurred vision and continued retching for an additional 5–10 min. Upon completion of the Epley maneuver, she experienced severe nausea and forceful vomiting for several minutes. Given the patient’s good functional status and overall health, she was felt to be an excellent candidate for the Epley maneuver, which was offered and agreed to, with slight subjective dizziness at all stations. Dix-Hallpike testing was strongly positive to the left, with subjective vertigo and fatigable nystagmus. The vestibuloocular reflex was intact, and there was no post head-shake nystagmus. On exam, there was no spontaneous or gaze-evoked nystagmus. She lived independently and was very active. She had no history of smoking or alcohol use. She took no medications, and had no allergies. There was no previous history of stroke or ischemic heart disease. Additionally, she had a right-sided cataract with stable vision. On presentation to our service she had been normotensive without medications. Her relevant past medical history included a remote diagnosis of hypertension. Her current state left her feeling unable to lie flat and she had cancelled cataract surgery as a result. She had similar problems approximately 15 months prior, which had resolved completely and spontaneously after three weeks. The episodes lasted several seconds before resolving spontaneously.

She complained of approximately 3 months of positional spinning sensation, worse with lying flat, or on her left side. Ī 77-year-old woman presented for otolaryngology consultation. This can be achieved through various canalith repositioning maneuvers, of which the most popular is the Epley maneuver.Īlthough certain forms of neck manipulation are felt to exacerbate ischemic strokes by cervical artery dissection, the Epley maneuver itself has strong evidence for safety and efficacy, with no serious adverse effects reported in the literature. Treatment of BPPV is primarily based on particle repositioning, by directing the canaliths into the utricle where they no longer stimulate the vestibular system. The diagnosis becomes definite when the Dix-Hallpike test elicits a fatiguable, reversible, torsional geotropic, paroxysmal nystagmus, accompanied by vertigo. This diagnosis is probable when the patients’ symptoms are reproduced with moving from sitting to a supine position, with the head in hanging position and turned 45° to the affected side. Although occasionally from secondary or acquired etiologies (as in post-trauma, vestibular neuritis, labyrinthitis, vertebrobasilar ischemia), the majority of cases are idiopathic in nature.īPPV diagnosis is typically confirmed by a Dix-Hallpike maneuver. The indirect causation and extreme rarity of this event do not warrant any change to patterns of practice.īenign paroxysmal positional vertigo (BPPV) is characterized by brief episodes of vertigo associated with changes in head position, and is the most common vestibular disorder. This case, in which a patient experienced a hemorrhagic stroke after undergoing the Epley maneuver, is the first and sole case in the medical literature of an Epley-associated serious adverse event. The Epley maneuver is safe and effective, and there are no prior reports of serious adverse events associated with its use. After medical stabilization and rehabilitation, the patient continues to have a permanent visual field deficit. A CT angiogram of the brain was performed urgently through the emergency department and demonstrated an acute intraparenchymal hemorrhage in the occipital lobe. Immediately following Epley maneuver, she had severe nausea and vomiting, with evolving visual changes. She was found to have BPPV clinically, and elected to have a particle repositioning maneuver (Epley maneuver) performed in clinic.

Case presentationĪ 77 year old female presented for outpatient evaluation of vertigo at a tertiary otolaryngology clinic. This is the first case to our knowledge of a serious adverse event following the Epley maneuver, which is the treatment of choice for benign paroxysmal positional vertigo (BPPV), the most common vestibular disorder in adults.

Vertigo maneuver