Vestibular paroxysmia

Vestibular paroxysmia is also referred to as disabling positional vertigo, vascular loop syndrome or microvascular compression syndrome in the literature. Other vascular compression syndromes include trigeminal neuralgia and hemifacial spasm. Vestibular paroxysmia is a controversial syndrome. It is believed that a blood vessel, which forms a loop around the vestibular branch of the cochleovestibular nerve (VIII cranial nerve) is responsible. This causes pressure on the nerve and short circuits in the nerve conduction. It is responsible for brief attacks of spinning vertigo (quick spins), postural vertigo and motion intolerance. The attacks are usually self-limiting. It can also be accompanied by tinnitus and hearing loss. Certain head positions  may trigger the symptoms. Symptoms  can get worse when a patient exercises or hyperventilates. However, the symptoms are non- specific. It can also be seen in patients with other conditions such as migraine, benign paroxysmal positional vertigo (BPPV), Meniere’s disease and perilymph fistula (PLF). During attack free intervals, patients can still be bothered by tinnitus and hearing loss. With examination a nystagmus can sometimes be seen. If the direction of the nystagmus reverses with hyperventilation it is suggestive of the condition. Hearing tests, auditory brainstem evoked responses (ABR) and video nystagmography (VNG) may be ordered.  A MRI can support the diagnosis of a vascular loop but unfortunately is not very specific.  Lots of people may show vascular loops on MRI but not have any symptoms. It is more important in excluding other causes. Patients can be treated with medication. In some selected cases a surgical procedure may be of value. The vascular loop can be seperated from the nerve. Decompression surgery is risky, not always successful and should  be reserved as a last resort.


A vascular loop responsible for vestibular paroxysmia

A vascular loop

Vascular loop shown by white arrow

A vascular loop on MRI, but is it responsible for the symptoms?